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Sample records for clinical decision-making part

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

    PubMed

    Hancock, Helen C; Durham, Lesley

    2007-04-01

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

  2. Clinical judgment and decision making.

    PubMed

    Garb, Howard N

    2005-01-01

    When clinical psychologists make judgments, are they likely to be correct or incorrect? The following topics are reviewed: (a) methodological advances in evaluating the validity of descriptions of personality and psychopathology, (b) recent findings on the cognitive processes of clinicians, and (c) the validity of judgments and utility of decisions made by mental health professionals. Results from research on clinical judgment and decision making and their relationship to conflicts within the field of clinical psychology are discussed.

  3. Effort-Based Decision-Making Paradigms for Clinical Trials in Schizophrenia: Part 2—External Validity and Correlates.

    PubMed

    Horan, William P; Reddy, L Felice; Barch, Deanna M; Buchanan, Robert W; Dunayevich, Eduardo; Gold, James M; Marder, Steven R; Wynn, Jonathan K; Young, Jared W; Green, Michael F

    2015-09-01

    Effort-based decision making has strong conceptual links to the motivational disturbances that define a key subdomain of negative symptoms. However, the extent to which effort-based decision-making performance relates to negative symptoms, and other clinical and functionally important variables has yet to be systematically investigated. In 94 clinically stable outpatients with schizophrenia, we examined the external validity of 5 effort-based paradigms, including the Effort Expenditure for Rewards, Balloon Effort, Grip Strength Effort, Deck Choice Effort, and Perceptual Effort tasks. These tasks covered 3 types of effort: physical, cognitive, and perceptual. Correlations between effort related performance and 6 classes of variables were examined, including: (1) negative symptoms, (2) clinically rated motivation and community role functioning, (3) self-reported motivational traits, (4) neurocognition, (5) other psychiatric symptoms and clinical/demographic characteristics, and (6) subjective valuation of monetary rewards. Effort paradigms showed small to medium relationships to clinical ratings of negative symptoms, motivation, and functioning, with the pattern more consistent for some measures than others. They also showed small to medium relations with neurocognitive functioning, but were generally unrelated to other psychiatric symptoms, self-reported traits, antipsychotic medications, side effects, and subjective valuation of money. There were relatively strong interrelationships among the effort measures. In conjunction with findings from a companion psychometric article, all the paradigms warrant further consideration and development, and 2 show the strongest potential for clinical trial use at this juncture.

  4. Effort-Based Decision-Making Paradigms for Clinical Trials in Schizophrenia: Part 2—External Validity and Correlates

    PubMed Central

    Reddy, L. Felice; Barch, Deanna M.; Buchanan, Robert W.; Dunayevich, Eduardo; Gold, James M.; Marder, Steven R.; Wynn, Jonathan K.; Young, Jared W.; Green, Michael F.

    2015-01-01

    Effort-based decision making has strong conceptual links to the motivational disturbances that define a key subdomain of negative symptoms. However, the extent to which effort-based decision-making performance relates to negative symptoms, and other clinical and functionally important variables has yet to be systematically investigated. In 94 clinically stable outpatients with schizophrenia, we examined the external validity of 5 effort-based paradigms, including the Effort Expenditure for Rewards, Balloon Effort, Grip Strength Effort, Deck Choice Effort, and Perceptual Effort tasks. These tasks covered 3 types of effort: physical, cognitive, and perceptual. Correlations between effort related performance and 6 classes of variables were examined, including: (1) negative symptoms, (2) clinically rated motivation and community role functioning, (3) self-reported motivational traits, (4) neurocognition, (5) other psychiatric symptoms and clinical/demographic characteristics, and (6) subjective valuation of monetary rewards. Effort paradigms showed small to medium relationships to clinical ratings of negative symptoms, motivation, and functioning, with the pattern more consistent for some measures than others. They also showed small to medium relations with neurocognitive functioning, but were generally unrelated to other psychiatric symptoms, self-reported traits, antipsychotic medications, side effects, and subjective valuation of money. There were relatively strong interrelationships among the effort measures. In conjunction with findings from a companion psychometric article, all the paradigms warrant further consideration and development, and 2 show the strongest potential for clinical trial use at this juncture. PMID:26209546

  5. 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…

  6. Strategies for Teaching Clinical Decision-Making.

    ERIC Educational Resources Information Center

    Boney, Jo; Baker, Jacqueline D.

    1997-01-01

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

  7. 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…

  8. Probability, clinical decision making and hypothesis testing

    PubMed Central

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

    2009-01-01

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

  9. Subjective measures and clinical decision making.

    PubMed

    Delitto, A

    1989-07-01

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

  10. Greater than the Parts: Shared Decision Making.

    ERIC Educational Resources Information Center

    Jensen, Anabel L.

    1986-01-01

    The article describes the goals, rationale, structure of the shared decision-making model in effect at the Nueva Learning Center, a private elementary school for gifted and talented in Hillsborough, California. An example applying the model to class scheduling and 10 steps for facilitating the process are given. (Author/DB)

  11. Dialogic Consensus In Clinical Decision-Making.

    PubMed

    Walker, Paul; Lovat, Terry

    2016-12-01

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

  12. 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.

  13. Thinking processes used by nurses in clinical decision making.

    PubMed

    Higuchi, Kathryn A Smith; Donald, Janet G

    2002-04-01

    Clinical decision making forms the basis of expert clinical practice. The purpose of this study was to investigate and document the thinking processes used by nurses in clinical decision making situations so the processes could guide educational practice. Clinical data was analyzed to reveal that clinical decision making is complex and requires a variety of thinking processes. Medical and surgical nurses used different thinking processes, showing the importance of context in clinical decision making. The nursing exemplars and working vocabulary developed in this study to describe the thinking processes used in clinical decision making can be used in nursing education.

  14. Entrustment Decision Making in Clinical Training.

    PubMed

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

    2016-02-01

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

  15. Clinical models of decision making in addiction.

    PubMed

    Koffarnus, Mikhail N; Kaplan, Brent A

    2017-08-26

    As research on decision making in addiction accumulates, it is increasingly clear that decision-making processes are dysfunctional in addiction and that this dysfunction may be fundamental to the initiation and maintenance of addictive behavior. How drug-dependent individuals value and choose among drug and nondrug rewards is consistently different from non-dependent individuals. The present review focuses on the assessment of decision-making in addiction. We cover the common behavioral tasks that have shown to be fruitful in decision-making research and highlight analytical and graphical considerations, when available, to facilitate comparisons within and among studies. Delay discounting tasks, drug demand tasks, drug choice tasks, the Iowa Gambling Task, and the Balloon Analogue Risk Task are included. Copyright © 2017 Elsevier Inc. All rights reserved.

  16. Patient decision-making for clinical genetics.

    PubMed

    Anderson, Gwen

    2007-03-01

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

  17. 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

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

    PubMed

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

    2006-06-01

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

  19. 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…

  20. 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.

  1. Best-fit model of exploratory and confirmatory factor analysis of the 2010 Medical Council of Canada Qualifying Examination Part I clinical decision-making cases.

    PubMed

    Champlain, André F De

    2015-01-01

    This study aims to assess the fit of a number of exploratory and confirmatory factor analysis models to the 2010 Medical Council of Canada Qualifying Examination Part I (MCCQE1) clinical decision-making (CDM) cases. The outcomes of this study have important implications for a range of domains, including scoring and test development. The examinees included all first-time Canadian medical graduates and international medical graduates who took the MCCQE1 in spring or fall 2010. The fit of one- to five-factor exploratory models was assessed for the item response matrix of the 2010 CDM cases. Five confirmatory factor analytic models were also examined with the same CDM response matrix. The structural equation modeling software program Mplus was used for all analyses. Out of the five exploratory factor analytic models that were evaluated, a three-factor model provided the best fit. Factor 1 loaded on three medicine cases, two obstetrics and gynecology cases, and two orthopedic surgery cases. Factor 2 corresponded to pediatrics, and the third factor loaded on psychiatry cases. Among the five confirmatory factor analysis models examined in this study, three- and four-factor lifespan period models and the five-factor discipline models provided the best fit. The results suggest that knowledge of broad disciplinary domains best account for performance on CDM cases. In test development, particular effort should be placed on developing CDM cases according to broad discipline and patient age domains; CDM testlets should be assembled largely using the criteria of discipline and age.

  2. Anatomic and functional leg-length inequality: A review and recommendation for clinical decision-making. Part II, the functional or unloaded leg-length asymmetry

    PubMed Central

    Knutson, Gary A

    2005-01-01

    Background Part II of this review examines the functional "short leg" or unloaded leg length alignment asymmetry, including the relationship between an anatomic and functional leg-length inequality. Based on the reviewed evidence, an outline for clinical decision making regarding functional and anatomic leg-length inequality will be provided. Methods Online databases: Medline, CINAHL and Mantis. Plus library searches for the time frame of 1970–2005 were done using the term "leg-length inequality". Results and Discussion The evidence suggests that an unloaded leg-length asymmetry is a different phenomenon than an anatomic leg-length inequality, and may be due to suprapelvic muscle hypertonicity. Anatomic leg-length inequality and unloaded functional or leg-length alignment asymmetry may interact in a loaded (standing) posture, but not in an unloaded (prone/supine) posture. Conclusion The unloaded, functional leg-length alignment asymmetry is a likely phenomenon, although more research regarding reliability of the measurement procedure and validity relative to spinal dysfunction is needed. Functional leg-length alignment asymmetry should be eliminated before any necessary treatment of anatomic LLI. PMID:16080787

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

    PubMed

    Rashotte, Judy; Carnevale, F A

    2004-07-01

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

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

    PubMed

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

    2010-12-01

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

  5. Cognitive Elements in Clinical Decision-Making

    ERIC Educational Resources Information Center

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

    2010-01-01

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

  6. Cognitive Elements in Clinical Decision-Making

    ERIC Educational Resources Information Center

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

    2010-01-01

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

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

    PubMed

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

    2008-07-01

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

  8. 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.

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

    ERIC Educational Resources Information Center

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

    2002-01-01

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

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

    ERIC Educational Resources Information Center

    Grembowski, David; And Others

    1989-01-01

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

  11. Spare parts inventory risk for decision making in plant maintenance

    NASA Astrophysics Data System (ADS)

    Sharif, Kamal Imran; Ibrahim, Jafni Azhan; Udin, Zulkifli Mohamed

    2016-08-01

    Equipment breakdown due to unavailability of spare parts is really disastrous in plant maintenance. The failure increase the cost of repair and production downtime. Therefore, it is important to understand the maintenance and inventory function in order to ensure the plant operate accordingly. Moreover, it is necessary for the plant maintenance to balance the issue of shortage and excess of inventory in plant maintenance. In view of this situation, the spare parts become a critical matters and it is good starting point to tackle the issues from looking at the perspective of spare parts inventory risk. This paper describes the development of risk technique for plant maintenance decision making purposes using the Shortage and Excess Impact Table. It also used the Breakdown Probability Table to quantify the risk for the spare part failure.

  12. Shared clinical decision making. A Saudi Arabian perspective.

    PubMed

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

    2015-12-01

    To determine preferences of patients regarding their involvement in the clinical decision making process and the related factors in Saudi Arabia.   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.  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).  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.

  13. [Treatment evaluation and clinical decision making using HKT-30-ROM].

    PubMed

    Ter Horst, P; van Ham, M; Spreen, M; Bogaerts, S

    2014-01-01

    By means of repeated, well-supported measurements of clinical dynamic indicators from the Historical, Clinical and Future - 30 (HKT-30) it is possible to monitor behavioural changes on the basis of risks and needs. The addition of extra score parameters allows us to distinguish client-specific risks and needs. In treatment evaluation it is important to visualise changes in these indicators of treatment evaluation because they are the key to the clinical decision-making process that determines further treatment and rehabilitation. To investigate whether HKT-30 indicators can be used to measure and visualise behavioral changes for the purpose of treatment evaluation. A case study is used to illustrate how clinicians at the Forensic Psychiatric Clinic (FPK), De Woenselse Poort, ascertain risks, needs and changes and clarify these factors for the purpose of treatment evaluation and clinical decision-making. Routine treatment evaluation aided by visualised clinical HKT-30 indicators give the treatment team and the client a clearer picture of the behavioral changes for which the forensic treatment was prescribed. This evaluation provides significant starting-points for clinical decision making. Routine treatment evaluation along with a suitably adjusted HKT-30 make behavioural changes visible, render clinical decisions more transparent and provide valuable starting-points for a dialogue with the client about his treatment.

  14. Remote clinical decision-making: a clinician's definition.

    PubMed

    Brady, Mike; Northstone, Kate

    2017-05-12

    Aims Remote clinical decision-making (RCDM), commonly known as 'telephone triage' or 'hear and treat', describes clinicians' non-face-to-face involvement with patient care, and is an established strategy in UK ambulance services for managing increasing demand. However, there is no suitable definition of RCDM that fully explains the roles undertaken by clinicians in 999 hubs, or for its use as an ambulance quality indicator (AQI). The aim of this study, which is part of a larger evaluation of a new RCDM module in higher education, is to determine how clinicians define RCDM. Methods Three participants were asked, during semi-structured interviews, to define RCDM. The interviews were recorded, transcribed and thematically analysed. Results Clinicians do not focus on outcomes when defining RCDM, but on the efficacy of the process and the appropriateness of the determined outcome. Conclusion There is no precise description of the role of healthcare professionals in 999 clinical hubs, but there is a need for role clarity, for employees and organisations. The study questions the suitability of the definition of hear and treat as an AQI, as it does not appear to represent fully the various duties undertaken by 999 clinical hub healthcare professionals. More research is needed to consider the definition of RCDM in all its forms.

  15. Effort-Based Decision-Making Paradigms for Clinical Trials in Schizophrenia: Part 1—Psychometric Characteristics of 5 Paradigms.

    PubMed

    Reddy, L Felice; Horan, William P; Barch, Deanna M; Buchanan, Robert W; Dunayevich, Eduardo; Gold, James M; Lyons, Naomi; Marder, Stephen R; Treadway, Michael T; Wynn, Jonathan K; Young, Jared W; Green, Michael F

    2015-09-01

    Impairments in willingness to exert effort contribute to the motivational deficits characteristic of the negative symptoms of schizophrenia. The current study evaluated the psychometric properties of 5 new or adapted paradigms to determine their suitability for use in clinical trials of schizophrenia. This study included 94 clinically stable participants with schizophrenia and 40 healthy controls. The effort-based decision-making battery was administered twice to the schizophrenia group (baseline, 4-week retest) and once to the control group. The 5 paradigms included 1 that assesses cognitive effort, 1 perceptual effort, and 3 that assess physical effort. Each paradigm was evaluated on (1) patient vs healthy control group differences, (2) test-retest reliability, (3) utility as a repeated measure (ie, practice effects), and (4) tolerability. The 5 paradigms showed varying psychometric strengths and weaknesses. The Effort Expenditure for Rewards Task showed the best reliability and utility as a repeated measure, while the Grip Effort Task had significant patient-control group differences, and superior tolerability and administration duration. The other paradigms showed weaker psychometric characteristics in their current forms. These findings highlight challenges in adapting effort and motivation paradigms for use in clinical trials.

  16. Effort-Based Decision-Making Paradigms for Clinical Trials in Schizophrenia: Part 1—Psychometric Characteristics of 5 Paradigms

    PubMed Central

    Reddy, L. Felice; Horan, William P.; Barch, Deanna M.; Buchanan, Robert W.; Dunayevich, Eduardo; Gold, James M.; Lyons, Naomi; Marder, Stephen R.; Treadway, Michael T.; Wynn, Jonathan K.; Young, Jared W.; Green, Michael F.

    2015-01-01

    Impairments in willingness to exert effort contribute to the motivational deficits characteristic of the negative symptoms of schizophrenia. The current study evaluated the psychometric properties of 5 new or adapted paradigms to determine their suitability for use in clinical trials of schizophrenia. This study included 94 clinically stable participants with schizophrenia and 40 healthy controls. The effort-based decision-making battery was administered twice to the schizophrenia group (baseline, 4-week retest) and once to the control group. The 5 paradigms included 1 that assesses cognitive effort, 1 perceptual effort, and 3 that assess physical effort. Each paradigm was evaluated on (1) patient vs healthy control group differences, (2) test-retest reliability, (3) utility as a repeated measure (ie, practice effects), and (4) tolerability. The 5 paradigms showed varying psychometric strengths and weaknesses. The Effort Expenditure for Rewards Task showed the best reliability and utility as a repeated measure, while the Grip Effort Task had significant patient-control group differences, and superior tolerability and administration duration. The other paradigms showed weaker psychometric characteristics in their current forms. These findings highlight challenges in adapting effort and motivation paradigms for use in clinical trials. PMID:26142081

  17. 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.

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

    PubMed Central

    Davis, Derik L; Morrison, James J

    2016-01-01

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

  19. Shared decision making as part of value based care: New U.S. policies challenge our readiness.

    PubMed

    Spatz, Erica S; Elwyn, Glyn; Moulton, Benjamin W; Volk, Robert J; Frosch, Dominick L

    2017-06-01

    Shared decision making in the United States is increasingly being recognized as part of value-based care. During the last decade, several state and federal initiatives have linked shared decision making with reimbursement and increased protection from litigation. Additionally, private and public foundations are increasingly funding studies to identify best practices for moving shared decision making from the research world into clinical practice. These shifts offer opportunities and challenges for ensuring effective implementation. Copyright © 2017. Published by Elsevier GmbH.

  20. Informing clinical policy decision-making practices in ambulance services.

    PubMed

    Muecke, Sandy; Curac, Nada; Binks, Darryn

    2013-12-01

    This study aims to identify the processes and frameworks that support an evidence-based approach to clinical policy decision-making practices in ambulance services. This literature review focused on: (i) the setting (pre-hospital); and (ii) the process of evidence translation, for studies published after the year 2000. Searches of Medline, CINAHL and Google were undertaken. Reference lists of eligible publications were searched for relevant articles. A total of 954 articles were identified. Of these, 20 full text articles were assessed for eligibility and seven full text articles met the inclusion criteria. Three provided detailed descriptions of the evidence-based practice processes used to inform ambulance service protocol or guideline development or review. There is little published literature that describes the processes involved, and frameworks required, to inform clinical policy decision making within ambulance services. This review found that processes were iterative and involved collaborations across many internal and external stakeholders. In several jurisdictions, these were coordinated by a dedicated team. Success appears dependent on committed leadership and purposive human and structural resources. Although time consuming, structured processes have been developed in some jurisdictions to assist decision-making processes. Further insight is likely to be obtained from literature published by those from other disciplines. © 2013 The Authors. International Journal of Evidence-Based Healthcare © 2013 The Joanna Briggs Institute.

  1. Nurses’ Use of Race in Clinical Decision Making

    PubMed Central

    Sellers, Sherrill L.; Moss, Melissa E.; Calzone, Kathleen; Abdallah, Khadijah E.; Jenkins, Jean F.; Bonham, Vence L.

    2017-01-01

    ancestry may increase in clinical decision making could allow nurses to more appropriately use of race in clinical care. Integrating patient demographic characteristics into clinical decisions is an important component of nursing practice. Clinical Relevance Registered nurses provide care for diverse racial and ethnic patient populations and stand on the front line of clinical care, making them essential for reducing racial and ethnic disparities in healthcare delivery. Exploring registered nurses’ individual-level characteristics and clinical use of race may provide a more comprehensive understanding of specific training needs and inform nursing education and practice. PMID:27676232

  2. Nurses' Use of Race in Clinical Decision Making.

    PubMed

    Sellers, Sherrill L; Moss, Melissa E; Calzone, Kathleen; Abdallah, Khadijah E; Jenkins, Jean F; Bonham, Vence L

    2016-11-01

    To examine nurses' self-reported use of race in clinical evaluation. This cross-sectional study analyzed data collected from three separate studies using the Genetics and Genomics in Nursing Practice Survey, which includes items about use of race and genomic information in nursing practice. The Racial Attributes in Clinical Evaluation (RACE) scale was used to measure explicit clinical use of race among nurses from across the United States. Multivariate regression analysis was used to examine associations between RACE score and individual-level characteristics and beliefs in 5,733 registered nurses. Analysis revealed significant relationships between RACE score and nurses' race and ethnicity, educational level, and views on the clinical importance of patient demographic characteristics. Asian nurses reported RACE scores 1.41 points higher than White nurses (p < .001), and Black nurses reported RACE scores 0.55 points higher than White nurses (p < .05). Compared to diploma-level nurses, the baccalaureate-level nurses reported 0.69 points higher RACE scores (p < .05), master's-level nurses reported 1.63 points higher RACE scores (p < .001), and doctorate-level nurses reported 1.77 points higher RACE scores (p < .01). In terms of clinical importance of patient characteristics, patient race and ethnicity corresponded to a 0.54-point increase in RACE score (p < .001), patient genes to a 0.21-point increase in RACE score (p < .001), patient family history to a 0.15-point increase in RACE score (p < .01), and patient age to a 0.19-point increase in RACE score (p < .001). Higher reported use of race among minority nurses may be due, in part, to differential levels of racial self-awareness. A relatively linear positive relationship between level of nursing degree nursing education and use of race suggests that a stronger foundation of knowledge about genetic ancestry, population genetics and the concept "race" and genetic ancestry may increase in clinical decision making

  3. Clinical model for ethical cardiopulmonary resuscitation decision-making.

    PubMed

    Hayes, B

    2013-01-01

    Decisions to withhold cardiopulmonary resuscitation (CPR) for future cardiac arrest continue to be problematic, with a lack of consistency in how doctors approach this decision. To develop a clinical model that can be used in education to improve consistency in CPR decision-making. A qualitative study, using semistructured interviews with a total of 33 senior doctors, junior doctors and nurses from two Melbourne hospitals explored how decisions to withhold CPR are made. Interviews explored: issues arising; how doctors learn to make these decisions; how they deal with disagreement and their experiences of performing CPR. The transcripts were coded and analysed thematically. Three major themes were identified: CPR as a life-and-death decision; good and bad dying; and trust. The research also defined the two elements to a CPR decision: (i) technical and (ii) ethical. Applying ethical principles commonly used in medicine, a model for ethical CPR decision-making has been developed that identifies four patient groups, each with a different discussion aim. This approach simplifies the complexities of the CPR decision, providing a structured way to teach CPR decision-making to doctors and thereby achieve greater consistency in the decisions made. © 2012 The Author; Internal Medicine Journal © 2012 Royal Australasian College of Physicians.

  4. 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.

  5. Clinical decision making in exercise prescription for fall prevention.

    PubMed

    Haas, Romi; Maloney, Stephen; Pausenberger, Eva; Keating, Jennifer L; Sims, Jane; Molloy, Elizabeth; Jolly, Brian; Morgan, Prue; Haines, Terry

    2012-05-01

    Physical therapists often prescribe exercises for fall prevention. Understanding the factors influencing the clinical decision-making processes used by expert physical therapists working in specialist fall and balance clinics may assist other therapists in prescribing exercises for fall prevention with greater efficacy. The objective of this study was to describe the factors influencing the clinical decision-making processes used by expert physical therapists to prescribe exercises for fall prevention. This investigation was a qualitative study from a phenomenological perspective. Semistructured telephone interviews were conducted with 24 expert physical therapists recruited primarily from the Victorian Falls Clinic Coalition. Interviews focused on 3 exercise prescription contexts: face-to-face individual therapy, group exercise programs, and home exercise programs. Interviews elicited information about therapist practices and the therapist, patient, and environmental factors influencing the clinical decision-making processes for the selection of exercise setting, type, dosage (intensity, quantity, rest periods, duration, and frequency), and progression. Strategies for promoting adherence and safety were also discussed. Data were analyzed with a framework approach by 3 investigators. Participants described highly individualized exercise prescription approaches tailored to address key findings from physical assessments. Dissonance between prescribing a program that was theoretically correct on the basis of physiological considerations and prescribing one that a client would adhere to was evident. Safety considerations also were highly influential on the exercise type and setting prescribed. Terminology for describing the intensity of balance exercises was vague relative to terminology for describing the intensity of strength exercises. Physical therapists with expertise in fall prevention adopted an individualized approach to exercise prescription that was based on

  6. Health care technology assessment: implications for modern medical practice. Part II. Decision making on technology adoption.

    PubMed

    Pierce, Read G; Bozic, Kevin J; Hall, Bruce Lee; Breivis, James

    2007-02-01

    Health care technology assessment, the multidisciplinary evaluation of clinical and economic aspects of technology, has come to have an increasingly important role in health policy and clinical decision-making. In Part I--Understanding Technology Adoption and Analyses--this review addressed the difficult challenges posed by assessment and provided a guide to the methodologies used. Part II presents the factors that drive the technology choices made by patients, by individual physicians, by provider groups, and by hospital administrators.

  7. 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

    2017-10-01

    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.

  8. How does Evidence Affect Clinical Decision-making?

    PubMed Central

    Fontelo, Paul; Liu, Fang; Uy, Raymonde C.

    2017-01-01

    In 1998, the “Evidence Cart” was introduced to provide decision-support tools at the point of care. A recent study showed that a majority of doctors who previously stated that evidence was not needed sought it nevertheless when it was easily available. In this study, invited clinicians were asked to rate the usefulness of evidence provided as abstracts and “the bottom-line summaries” (TBL) using a modified version of a Web app for searching PubMed and then specify reasons how it might affect their clinical decision-making. The responses were captured in the server’s log. One hundred and one reviews were submitted with 22 reviews for abstracts and 79 for TBLs. The overall usefulness Likert score (1=least useful, 7=most useful) was 5.02±1.96 (4.77±2.11 for abstracts and 5.09±1.92 for TBL). The basis for scores was specified in only about half (53/101) of reviews. The most frequent single reason (32%) was that it led to a new skill, diagnostic test, or treatment plan. Two or more reasons were given in 16 responses (30.2%). Two-thirds more responders used TBL summaries than abstracts confirming further that clinicians prefer convenient easy-to-read evidence at the point of care. This study seems to show similar results as the Evidence Cart study on the usefulness of evidence in clinical decision-making. PMID:26337628

  9. Clinical decision making-a functional medicine perspective.

    PubMed

    Pizzorno, Joseph E

    2012-09-01

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

  10. Aeronautical Decision Making in Part 141 Flight Schools.

    ERIC Educational Resources Information Center

    Bowman, Terry S.; Krongos, Kenneth M.

    1995-01-01

    Data from a survey of 96 (of 534) flight training programs seem to indicate a high percentage include Aeronautical Decision Making (ADM) training, which has high potential for accident prevention. However, these results are due more to social desirability bias. Only 38 use all 10 ADM topics; of the one textbook mentioning ADM, only 2% of the…

  11. 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

  12. Incorporating clinical guidelines through clinician decision-making

    PubMed Central

    Falzer, Paul R; Moore, Brent A; Garman, D Melissa

    2008-01-01

    Background It is generally acknowledged that a disparity between knowledge and its implementation is adversely affecting quality of care. An example commonly cited is the failure of clinicians to follow clinical guidelines. A guiding assumption of this view is that adherence should be gauged by a standard of conformance. At least some guideline developers dispute this assumption and claim that their efforts are intended to inform and assist clinical practice, not to function as standards of performance. However, their ability to assist and inform will remain limited until an alternative to the conformance criterion is proposed that gauges how evidence-based guidelines are incorporated into clinical decisions. Methods The proposed investigation has two specific aims to identify the processes that affect decisions about incorporating clinical guidelines, and then to develop ad test a strategy that promotes the utilization of evidence-based practices. This paper focuses on the first aim. It presents the rationale, introduces the clinical paradigm of treatment-resistant schizophrenia, and discusses an exemplar of clinician non-conformance to a clinical guideline. A modification of the original study is proposed that targets psychiatric trainees and draws on a cognitively rich theory of decision-making to formulate hypotheses about how the guideline is incorporated into treatment decisions. Twenty volunteer subjects recruited from an accredited psychiatry training program will respond to sixty-four vignettes that represent a fully crossed 2 × 2 × 2 × 4 within-subjects design. The variables consist of criteria contained in the clinical guideline and other relevant factors. Subjects will also respond to a subset of eight vignettes that assesses their overall impression of the guideline. Generalization estimating equation models will be used to test the study's principal hypothesis and perform secondary analyses. Implications The original design of phase two of the

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

    PubMed

    Coombs, Maureen

    2003-06-01

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

  14. Computers in pharmacokinetics. Choosing software for clinical decision making.

    PubMed

    Buffington, D E; Lampasona, V; Chandler, M H

    1993-09-01

    Over the past 20 years, pharmacokinetic programs have been developed for clinical decision making. These clinical pharmacokinetic software programs are designed to assist the clinician in the analysis, interpretation and reporting of serum drug concentration data for a variety of medications. The programs vary in the extent of features and range of medications supported and thus warrant careful review before selecting or purchasing such a program for routine use. A series of programs which are commercially available in the United States was reviewed for this article. The focus of the review is not to recommend a single program or to provide a ranked list of commercially available programs. Information is presented to clinicians to better their understanding of the features of these computer-based clinical resources. As an introduction to this topic, the information presented concentrates on the system and support features. Those programs that were reviewed demonstrate the ability to assist in the analysis of serum or plasma drug concentration data for most of the medications that warrant therapeutic drug monitoring. They provide both Bayesian and non-Bayesian methods for predicting serum drug concentrations. Standard personal computers were sufficient to run each of the programs reviewed. In addition, most programs offered technical and clinical support. However, the quality of the user manuals and training material varies among software programs. In-depth analytical comparisons are currently being conducted for future publication.

  15. 44 CFR Appendix A to Part 9 - Decision-making Process for E.O. 11988

    Code of Federal Regulations, 2010 CFR

    2010-10-01

    ... 44 Emergency Management and Assistance 1 2010-10-01 2010-10-01 false Decision-making Process for E.O. 11988 A Appendix A to Part 9 Emergency Management and Assistance FEDERAL EMERGENCY MANAGEMENT..., App. A Appendix A to Part 9—Decision-making Process for E.O. 11988 EC02FE91.074 ...

  16. 44 CFR Appendix A to Part 9 - Decision-making Process for E.O. 11988

    Code of Federal Regulations, 2014 CFR

    2014-10-01

    ... 44 Emergency Management and Assistance 1 2014-10-01 2014-10-01 false Decision-making Process for E.O. 11988 A Appendix A to Part 9 Emergency Management and Assistance FEDERAL EMERGENCY MANAGEMENT..., App. A Appendix A to Part 9—Decision-making Process for E.O. 11988 EC02FE91.074 ...

  17. 44 CFR Appendix A to Part 9 - Decision-making Process for E.O. 11988

    Code of Federal Regulations, 2013 CFR

    2013-10-01

    ... 44 Emergency Management and Assistance 1 2013-10-01 2013-10-01 false Decision-making Process for E.O. 11988 A Appendix A to Part 9 Emergency Management and Assistance FEDERAL EMERGENCY MANAGEMENT..., App. A Appendix A to Part 9—Decision-making Process for E.O. 11988 EC02FE91.074 ...

  18. 44 CFR Appendix A to Part 9 - Decision-making Process for E.O. 11988

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... 44 Emergency Management and Assistance 1 2011-10-01 2011-10-01 false Decision-making Process for E.O. 11988 A Appendix A to Part 9 Emergency Management and Assistance FEDERAL EMERGENCY MANAGEMENT..., App. A Appendix A to Part 9—Decision-making Process for E.O. 11988 EC02FE91.074 ...

  19. 44 CFR Appendix A to Part 9 - Decision-making Process for E.O. 11988

    Code of Federal Regulations, 2012 CFR

    2012-10-01

    ... 44 Emergency Management and Assistance 1 2012-10-01 2011-10-01 true Decision-making Process for E.O. 11988 A Appendix A to Part 9 Emergency Management and Assistance FEDERAL EMERGENCY MANAGEMENT..., App. A Appendix A to Part 9—Decision-making Process for E.O. 11988 EC02FE91.074 ...

  20. [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.

  1. Impact of dysphagia severity on clinical decision making via telerehabilitation.

    PubMed

    Ward, Elizabeth C; Burns, Clare L; Theodoros, Deborah G; Russell, Trevor G

    2014-04-01

    Recent research supports the proposal that valid and reliable clinical swallow examinations (CSEs) can be conducted via telerehabilitation. However, no studies have explored whether dysphagia severity has an impact on the success of the session or its outcomes. The current study examined how dysphagia severity impacted on either (a) clinical decision making for safety of oral intake or (b) clinician perceptions of CSEs conducted via telerehabilitation. One hundred patients (25 nondysphagics and 25 mild, 25 moderate, and 25 severe dysphagics) were assessed using a telehealth system and methodology reported in prior research. For each assessment, the online and face-to-face (FTF) clinicians simultaneously completed a structured CSE. On session completion, the online clinician indicated level of agreement with two statements regarding the level of rapport and ability to competently assess the patient. In each of the four groups, acceptable levels of agreement were observed between raters for the three primary outcomes (decisions regarding oral/nonoral intake and safe food and fluids) as well as over 90% of the CSE items. Clinicians agreed they could develop good rapport with the majority of patients in all groups. However, for a small but significant (p<0.5) proportion of patents in the severe dysphagic group, clinicians disagreed they were able to satisfactorily and competently assess to the best of their abilities using the telerehabilitation system. Clinical decisions made during and as an outcome of the total CSE were found to be comparable to those made in the FTF environment regardless of dysphagia severity. Clinicians noted some difficulty assessing patients with greater complexity, which occurred in greater numbers in the group with severe dysphagia.

  2. Biostatistics in clinical decision making for cardiothoracic radiologists.

    PubMed

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

    2013-11-01

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

  3. An exploration of the correlates of nurse practitioners' clinical decision-making abilities.

    PubMed

    Chen, Shiah-Lian; Hsu, Hsiu-Ying; Chang, Chin-Fu; Lin, Esther Ching-Lan

    2016-04-01

    This study investigated nurse practitioners' clinical decision-making abilities and the factors that affect these abilities. Nurse practitioners play an important role in clinical care decision-making; however, studies exploring the factors that affect their decision-making abilities are lacking. A cross-sectional descriptive survey was employed. A purposive sample of 197 nurse practitioners was recruited from a medical centre in central Taiwan. Structured questionnaires consisting of the Knowledge Readiness Scale, the Critical Thinking Disposition Inventory and the Clinical Decision-Making Model Inventory were used to collect data. The intuitive-analytical type was the most commonly used decision-making model, and the intuitive type was the least frequently used model. The decision-making model used was significantly related to the nurse practitioners' work unit. Significant differences were noted between the nurse practitioners' clinical decision-making models and their critical thinking dispositions (openness and empathy). The nurse practitioners' years of work experience, work unit, professional knowledge and critical thinking disposition (openness and empathy as well as holistic and reflective dispositions) predicted the nurse practitioners' analytical decision-making scores. Age, years of nurse practitioner work experience, work unit and critical thinking disposition (holistic and reflective) predicted the nurse practitioners' intuitive decision-making scores. This study contributes to the topic of clinical decision-making by describing various types of nurse practitioner decision-making. The factors associated with analytic and intuitive decision-making scores were identified. These findings might be beneficial when planning continuing education programmes to enhance the clinical decision-making abilities of nurse practitioners. The study results showed that nurse practitioners demonstrated various clinical decision-making types across different work units

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

    ERIC Educational Resources Information Center

    Byrne, Aidan

    2013-01-01

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

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

    ERIC Educational Resources Information Center

    Byrne, Aidan

    2013-01-01

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

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

    PubMed

    Chen, Lu-Yen A; Fawcett, Tonks N

    2016-10-01

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

  7. 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.

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

    PubMed Central

    Hudson, Donna L.; Estrin, Thelma

    1981-01-01

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

  9. Clinical data warehousing for evidence based decision making.

    PubMed

    Narra, Lekha; Sahama, Tony; Stapleton, Peta

    2015-01-01

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

  10. Team effort: the nuclear medicine decision making process. Part II.

    PubMed

    Tsuchiyama, S

    1991-06-01

    This two part article examines the nuclear medicine purchase of Baptist Memorial Hospital in Memphis, the largest private hospital in the nation. Part I (May 1991) focused on what their needs were. This concluding installment looks at the committee mechanism itself and the reasoning that went behind their decisions.

  11. Assessing clinical decision making: is the ideal system feasible?

    PubMed

    Dubois, R W; Brook, R H

    1988-01-01

    While caring for patients, physicians make a variety of decisions. Can current methods adequately determine whether these decisions are correct? If not, what improvements are needed? This paper begins with a review of several explicit methods to assess physician decision making. It then describes a more comprehensive system that would use Bayesian logic to assess whether a physician responded appropriately to the needs of an individual patient. Although sophisticated branching logic may be theoretically desirable, it may not be feasible. The paper concludes by proposing an explicit, potentially practical method that would judiciously use branching logic.

  12. 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.

  13. The unconscious thought effect in clinical decision making: an example in diagnosis.

    PubMed

    de Vries, Marieke; Witteman, Cilia L M; Holland, Rob W; Dijksterhuis, Ap

    2010-01-01

    The unconscious thought effect refers to improved judgments and decisions after a period of distraction. The authors studied the unconscious thought effect in a complex and error-prone part of clinical decision making: diagnosis. Their aim was to test whether conscious versus unconscious processing influenced diagnosis of psychiatric cases. They used case descriptions from the DSM-IV casebook. Half of the participants were randomly assigned to the conscious-processing-condition (i.e., consciously thinking about the information they read in the case description), the other half to the unconscious-processing condition (i.e., performing an unrelated distracter task). The main dependent measure was the total number of correct classifications. Compared to conscious processing, unconscious processing significantly increased the number of correct classifications. The results show the potential merits of unconscious processing in diagnostic decision making.

  14. 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.

  15. 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…

  16. 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.…

  17. 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.…

  18. 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…

  19. 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…

  20. Teleconsultation and Clinical Decision Making: a Systematic Review

    PubMed Central

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

    2016-01-01

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

  1. [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.

  2. 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.

  3. Uncertainty and objectivity in clinical decision making: a clinical case in emergency medicine.

    PubMed

    Engebretsen, Eivind; Heggen, Kristin; Wieringa, Sietse; Greenhalgh, Trisha

    2016-12-01

    The evidence-based practice and evidence-based medicine (EBM) movements have promoted standardization through guideline development methodologies based on systematic reviews and meta-analyses of best available research. EBM has challenged clinicians to question their reliance on practical reasoning and clinical judgement. In this paper, we argue that the protagonists of EBM position their mission as reducing uncertainty through the use of standardized methods for knowledge evaluation and use. With this drive towards uniformity, standardization and control comes a suspicion towards intuition, creativity and uncertainty as integral parts of medical practice. We question the appropriateness of attempts to standardize professional practice through a discussion of the importance of uncertainty. Greenhalgh's taxonomy of uncertainty is used to inform an analysis of the clinical reasoning occurring in a potentially life threatening emergency situation with a young patient. The case analysis is further developed by the use of the Canadian philosopher Bernard Lonergan's theory about understanding and objective knowing. According to Lonergan it is not by getting rid of or even by reducing uncertainty, but by attending systematically to it and by relating to it in a self-conscious way, that objective knowledge can be obtained. The paper concludes that uncertainty is not a regrettable and unavoidable aspect of decision making but a productive component of clinical reasoning.

  4. 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

  5. Detecting fast, online reasoning processes in clinical decision making.

    PubMed

    Flores, Amanda; Cobos, Pedro L; López, Francisco J; Godoy, Antonio

    2014-06-01

    In an experiment that used the inconsistency paradigm, experienced clinical psychologists and psychology students performed a reading task using clinical reports and a diagnostic judgment task. The clinical reports provided information about the symptoms of hypothetical clients who had been previously diagnosed with a specific mental disorder. Reading times of inconsistent target sentences were slower than those of control sentences, demonstrating an inconsistency effect. The results also showed that experienced clinicians gave different weights to different symptoms according to their relevance when fluently reading the clinical reports provided, despite the fact that all the symptoms were of equal diagnostic value according to the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; American Psychiatric Association, 2000). The diagnostic judgment task yielded a similar pattern of results. In contrast to previous findings, the results of the reading task may be taken as direct evidence of the intervention of reasoning processes that occur very early, rapidly, and online. We suggest that these processes are based on the representation of mental disorders and that these representations are particularly suited to fast retrieval from memory and to making inferences. They may also be related to the clinicians' causal reasoning. The implications of these results for clinician training are also discussed.

  6. 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…

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

    ERIC Educational Resources Information Center

    Sibold, Jeremy

    2012-01-01

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

  8. Patient factors that influence clinicians' decision making in self-management support: A clinical vignette study.

    PubMed

    Bos-Touwen, Irene D; Trappenburg, Jaap C A; van der Wulp, Ineke; Schuurmans, Marieke J; de Wit, Niek J

    2017-01-01

    Self-management support is an integral part of current chronic care guidelines. The success of self-management interventions varies between individual patients, suggesting a need for tailored self-management support. Understanding the role of patient factors in the current decision making of health professionals can support future tailoring of self-management interventions. The aim of this study is to identify the relative importance of patient factors in health professionals' decision making regarding self-management support. A factorial survey was presented to primary care physicians and nurses. The survey consisted of clinical vignettes (case descriptions), in which 11 patient factors were systematically varied. Each care provider received a set of 12 vignettes. For each vignette, they decided whether they would give this patient self-management support and whether they expected this support to be successful. The associations between respondent decisions and patient factors were explored using ordered logit regression. The survey was completed by 60 general practitioners and 80 nurses. Self-management support was unlikely to be provided in a third of the vignettes. The most important patient factor in the decision to provide self-management support as well as in the expectation that self-management support would be successful was motivation, followed by patient-provider relationship and illness perception. Other factors, such as depression or anxiety, education level, self-efficacy and social support, had a small impact on decisions. Disease, disease severity, knowledge of disease, and age were relatively unimportant factors. This is the first study to explore the relative importance of patient factors in decision making and the expectations regarding the provision of self-management support to chronic disease patients. By far, the most important factor considered was patient's motivation; unmotivated patients were less likely to receive self-management support

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

    PubMed

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

    2011-01-01

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

  10. Cholinesterase inhibitors: applying pharmacokinetics to clinical decision making.

    PubMed

    Gomolin, Irving H; Smith, Candace; Jeitner, Thomas M

    2011-08-01

    Cholinesterase inhibitors are indicated for the treatment of Alzheimer-type dementia. There are few direct comparative studies of adverse effects or studies to suggest clinical superiority of one inhibitor over the others. The objective of this study was to relate pharmacokinetic differences among the agents to potential clinical considerations. Population pharmacokinetics were obtained from US Food and Drug Administration-approved label information and published literature. Plasma concentration-time profiles were derived from these parameters using noncompartmental pharmacokinetic modeling. Plasma concentration profiles differed significantly among different agents and between different formulations of the same agent. The initial choice among the various cholinesterase inhibitors requires consideration to adherence and cost. Consideration to differences in pharmacokinetics among these drugs provides a better understanding for the clinical practice of dose titration, identification and management of drug-related side effects, and lapses in therapy. Pharmacokinetic considerations among the various agents and formulations provide the clinician with options to enhance therapy when these agents are chosen for treatment of patients with Alzheimer-type dementia. Copyright © 2011 Elsevier HS Journals, Inc. All rights reserved.

  11. Complexity perspectives on clinical decision making in an intensive care unit.

    PubMed

    de Bock, Ben A; Willems, Dick L; Weinstein, Henry C

    2017-08-01

    How to clarify the implications of complexity thinking for decision making in the intensive care unit (ICU)? Retrospective qualitative empirical research. Practitioners in an ICU were interviewed on how their decisions were made regarding a particular patient in a difficult, clinical situation. Transcriptions of these interviews were coded and retrieved in Maxqda, a software program. Assisted by complexity thinking, researchers focused on the decision-making process and the shift from analytic approaches to complex approaches. Originally, practitioners took their decisions with negligible transdisciplinary interactivity, drawing on analytical knowledge. Later on, they shifted to transdisciplinary practices, paying attention to more participation in their decision-making processes within their complex environment. Complexity thinking demonstrates that this is a better model towards understanding transdisciplinary decision making then most analytical methodologies. © 2017 John Wiley & Sons, Ltd.

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

    PubMed

    Légaré, France; Witteman, Holly O

    2013-02-01

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

  13. Clinical decision making in seizures and status epilepticus.

    PubMed

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

    2015-01-01

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

  14. 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.

  15. Quantitative ultrasound texture analysis for clinical decision making support

    NASA Astrophysics Data System (ADS)

    Wu, Jie Ying; Beland, Michael; Konrad, Joseph; Tuomi, Adam; Glidden, David; Grand, David; Merck, Derek

    2015-03-01

    We propose a general ultrasound (US) texture-analysis and machine-learning framework for detecting the presence of disease that is suitable for clinical application across clinicians, disease types, devices, and operators. Its stages are image selection, image filtering, ROI selection, feature parameterization, and classification. Each stage is modular and can be replaced with alternate methods. Thus, this framework is adaptable to a wide range of tasks. Our two preliminary clinical targets are hepatic steatosis and adenomyosis diagnosis. For steatosis, we collected US images from 288 patients and their pathology-determined values of steatosis (%) from biopsies. Two radiologists independently reviewed all images and identified the region of interest (ROI) most representative of the hepatic echotexture for each patient. To parameterize the images into comparable quantities, we filter the US images at multiple scales for various texture responses. For each response, we collect a histogram of pixel features within the ROI, and parameterize it as a Gaussian function using its mean, standard deviation, kurtosis, and skew to create a 36-feature vector. Our algorithm uses a support vector machine (SVM) for classification. Using a threshold of 10%, we achieved 72.81% overall accuracy, 76.18% sensitivity, and 65.96% specificity in identifying steatosis with leave-ten-out cross-validation (p<0.0001). Extending this framework to adenomyosis, we identified 38 patients with MR-confirmed findings of adenomyosis and previous US studies and 50 controls. A single rater picked the best US-image and ROI for each case. Using the same processing pipeline, we obtained 76.14% accuracy, 86.00% sensitivity, and 63.16% specificity with leave-one-out cross-validation (p<0.0001).

  16. The development and validation of the clinicians' awareness towards cognitive errors (CATChES) in clinical decision making questionnaire tool.

    PubMed

    Chew, Keng Sheng; Kueh, Yee Cheng; Abdul Aziz, Adlihafizi

    2017-03-21

    Despite their importance on diagnostic accuracy, there is a paucity of literature on questionnaire tools to assess clinicians' awareness toward cognitive errors. A validation study was conducted to develop a questionnaire tool to evaluate the Clinician's Awareness Towards Cognitive Errors (CATChES) in clinical decision making. This questionnaire is divided into two parts. Part A is to evaluate the clinicians' awareness towards cognitive errors in clinical decision making while Part B is to evaluate their perception towards specific cognitive errors. Content validation for both parts was first determined followed by construct validation for Part A. Construct validation for Part B was not determined as the responses were set in a dichotomous format. For content validation, all items in both Part A and Part B were rated as "excellent" in terms of their relevance in clinical settings. For construct validation using exploratory factor analysis (EFA) for Part A, a two-factor model with total variance extraction of 60% was determined. Two items were deleted. Then, the EFA was repeated showing that all factor loadings are above the cut-off value of >0.5. The Cronbach's alpha for both factors are above 0.6. The CATChES questionnaire tool is a valid questionnaire tool aimed to evaluate the awareness among clinicians toward cognitive errors in clinical decision making.

  17. 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.

  18. Theory of mind deficits partly mediate impaired social decision-making in schizophrenia.

    PubMed

    Yang, Liuqing; Li, Peifu; Mao, Haiying; Wang, Huiling; Shu, Chang; Bliksted, Vibeke; Zhou, Yuan

    2017-05-05

    Using paradigms from game theory, researchers have reported abnormal decision-making in social context in patients with schizophrenia. However, less is known about the underpinnings of the impairment. This study aimed to test whether theory of mind (ToM) deficits and/or neurocognitive dysfunctions mediate impaired social decision-making in patients with schizophrenia. We compared thirty-five patients with schizophrenia to thirty-eight matched healthy controls with regard to social decision-making using the mini Ultimatum Game (mini UG), a paradigm from game theory. Additionally, we assessed ToM using the Theory of Mind Picture Stories Task, a mental state attribution task, and assessed neurocognition using the Brief Assessment of Cognition in Schizophrenia. Mediation analyses were performed on the data. In contrast to the behavioral pattern of healthy controls in the mini UG, the patients with schizophrenia significantly accepted more disadvantageous offers and rejected more advantageous offers, and showed reduced sensitivity to the fairness-related context changes in the mini UG. Impaired ToM and neurocognition were also found in the patients. Mediation analyses indicated that ToM but not neurocognition partially mediated the group differences on the disadvantageous and advantageous offers in the mini UG. Patients with schizophrenia exhibited impaired social decision-making. This impairment can be partly explained by their ToM deficits rather than neurocognitive deficits. However, the exact nature of the ToM deficits that mediate impaired social decision-making needs to be identified in future.

  19. 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…

  20. Developing Key-Feature Problems and Examinations to Assess Clinical Decision-Making Skills.

    ERIC Educational Resources Information Center

    Page, Gordon; And Others

    1995-01-01

    An approach to testing medical students' clinical decision-making skills identifies key features (critical steps in resolution of a clinical problem) and presents a clinical case scenario followed by questions focusing on those key features. Key-feature problems provide flexibility on issues of question format, multiple responses to questions, and…

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

    PubMed

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

    2004-04-06

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

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

    PubMed Central

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

    2004-01-01

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

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

    PubMed

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

    2017-10-06

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

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

    PubMed

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

    2017-02-24

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

  5. Exploring the use of large clinical data to inform patients for shared decision making.

    PubMed

    Hill, Brent; Proulx, Joshua; Zeng-Treitler, Qing

    2013-01-01

    Barriers to patient participation in the shared decision making process prevent patients from fully participating in evaluating treatment options and treatment selection. Patients who use a decision aid are more informed and engaged in the shared decision making process. Patient decision aids do not use real clinical data for patient information and may not represent the data well. We designed an interface, for a shared decision making aid, that leverages clinical data to inform risk ratios and create patient stories, or vignettes, and present a visual representation of quantified treatment outcomes data. Usability testing was conducted with experts to evaluate the interface and the utility of using real clinical information that patients can explore. The experts' comments were transcribed and coded for themes. Themes were quantified and comments were interpreted for refinement and modification to the patient decision aid interface and data visualization.

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

    PubMed

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

    2016-10-03

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

  7. Do MRI Structured Reports for Multiple Sclerosis Contain Adequate Information for Clinical Decision-Making?

    PubMed

    Alessandrino, Francesco; Pichiecchio, Anna; Mallucci, Giulia; Ghione, Emanuele; Romani, Alfredo; Bergamaschi, Roberto; Bastianello, Stefano

    2017-09-27

    Few data are available on how often MRI reports provide sufficient information for clinical decision-making in patients with multiple sclerosis (MS). The aim of this study is to evaluate if structured reporting of MRI in MS contain adequate information for clinical decision-making compared with nonstructured reporting. Brain and spinal cord MRI reports of patients with suspected or known MS before and after implementation of a structured reporting template were included. Brain and spinal cord MRI reports were assessed for presence of 11 and three key features relevant for management of MS, respectively. Three neurologists evaluated reports and images to assess lesion load, presence of sufficient information for clinical decision-making, and necessity to review MR images for clinical decision-making. Statistical analysis included t tests and chi-square tests. Thirty-two structured and 37 nonstructured reports were reviewed. Brain MRI nonstructured reports contained a mean ± SD of 3.59 ± 0.76 key features, and structured reports contained a mean of 10.25 ± 1.32 key features (p < 0.001). No significant difference was observed in the number of key features in nonstructured and structured spinal cord MRI reports. All neurologists could understand lesion load significantly more often when reading structured versus nonstructured reports (p < 0.001). For two of the three neurologists, structured reports contained adequate information for clinical decision-making more often than did nonstructured reports (p < 0.001 and p = 0.006). When reading nonstructured reports, two of the three neurologists needed to evaluate images significantly more often (p < 0.001). Structured reports of MRI in patients with MS provided more adequate information for clinical decision-making than nonstructured reports.

  8. 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.

  9. 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

  10. 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…

  11. 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…

  12. 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…

  13. 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.

  14. Clinical decision making in the recognition of dying: a qualitative interview study.

    PubMed

    Taylor, Paul; Dowding, Dawn; Johnson, Miriam

    2017-01-25

    Recognising dying is an essential clinical skill for general and palliative care professionals alike. Despite the high importance, both identification and good clinical care of the dying patient remains extremely difficult and often controversial in clinical practice. This study aimed to answer the question: "What factors influence medical and nursing staff when recognising dying in end-stage cancer and heart failure patients?" This study used a descriptive approach to decision-making theory. Participants were purposively sampled for profession (doctor or nurse), specialty (cardiology or oncology) and grade (senior vs junior). Recruitment continued until data saturation was reached. Semi-structured interviews were conducted with NHS medical and nursing staff in an NHS Trust which contained cancer and cardiology tertiary referral centres. An interview schedule was designed, based on decision-making literature. Interviews were audio-recorded and transcribed and analysed using thematic framework. Data were managed with Atlas.ti. Saturation was achieved with 19 participants (7 seniors; 8 intermediate level staff; 4 juniors). There were 11 oncologists (6 doctors, 5 nurses) and 8 cardiologists (3 doctors, 5 nurses). Six themes were generated: information used; decision processes; modifying factors; implementation; reflecting on decisions and related decisions. The decision process described was time-dependent, ongoing and iterative, and relies heavily on intuition. This study supports the need to recognise the strengths and weaknesses of expertise and intuition as part of the decision process, and of placing the recognition of dying in a time-dependent context. Clinicians should also be prepared to accept and convey the uncertainty surrounding these decisions, both in practice and in communication with patients and carers.

  15. 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.

  16. Dentists' restorative decision-making and implications for an 'amalgamless' profession. Part 2: a qualitative study.

    PubMed

    Alexander, G; Hopcraft, M S; Tyas, M J; Wong, R H K

    2014-12-01

    In some countries the use of amalgam has been restricted, and the dental profession may be forced into using alternatives to amalgam by a combination of public opinion and legislation, including the proposal that the material be 'phased-down'. The limited research that exists as to restorative decision-making is quantitative in nature and focuses on 'when' a restoration is placed. There is little qualitative research exploring 'why' a material is chosen. Purposive sampling of a representative group of dentists registered in Australia was carried out in two phases; initially six interviews followed by a focus group of six different participants who were audio-recorded. Qualitative data were analysed using computer aided qualitative data analysis software. The findings suggest that dentists' restorative decision-making is a complex interplay of factors. These may be categorized as 'clinical', 'knowledge', 'patient', 'practice type', 'biological' and 'environmental'. Use of amalgam is influenced by each of these to varying degrees. Quantitative analysis of the influences on restorative decision-making is recommended. While the potential future 'phase-down' of amalgam as a restorative material was of concern, there was a general sense of resignation or apathy to the matter. The implications for public health authorities, dental organizations and educators are noted. © 2014 Australian Dental Association.

  17. 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.

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

    PubMed

    Logan, Gemma

    2015-03-01

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

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

    PubMed Central

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

    2015-01-01

    Objective Impairment in reward processes has been found in individuals with depression and in the aging population. The purpose of this study was twofold: 1. To use an affective neuroscience probe to identify abnormalities in reward-related decision making in late-life depression. 2. To examine the relationship of reward-related decision making abnormalities in depressed, older adults to the clinical expression of apathy in depression. We hypothesized that relative to elderly, healthy subjects, depressed, elderly patients would exhibit impaired decision making and that apathetic, depressed patients would show greater impairment in decision making than non-apathetic, depressed patients. Methods We used the Iowa Gambling Task to examine reward-related decision making in 60 non-demented, elderly patients with non-psychotic major depression and 36 elderly, psychiatrically healthy participants. Apathy was quantified using the Apathy Evaluation Scale. Of those with major depression, 18 individuals reported clinically significant apathy whereas 42 participants did not have apathy. Results Older adults with depression and healthy comparison participants did not differ in their performance on the IGT. However, apathetic, depressed older adults adopted an advantageous strategy and selected cards from the conservative decks compared to non-apathetic, depressed older adults. Non-apathetic, depressed patients showed a failure to adopt a conservative strategy and persisted in making risky decisions throughout the task. Conclusions This study indicates that apathy in older, depressed adults is associated with a conservative response style on a behavioral probe of the systems involved in reward-related decision making. This conservative response style may be the result of reduced sensitivity to rewards in apathetic individuals. PMID:25306937

  20. Patient factors that influence clinicians’ decision making in self-management support: A clinical vignette study

    PubMed Central

    Bos-Touwen, Irene D.; Trappenburg, Jaap C. A.; van der Wulp, Ineke; Schuurmans, Marieke J.; de Wit, Niek J.

    2017-01-01

    Background and aim Self-management support is an integral part of current chronic care guidelines. The success of self-management interventions varies between individual patients, suggesting a need for tailored self-management support. Understanding the role of patient factors in the current decision making of health professionals can support future tailoring of self-management interventions. The aim of this study is to identify the relative importance of patient factors in health professionals’ decision making regarding self-management support. Method A factorial survey was presented to primary care physicians and nurses. The survey consisted of clinical vignettes (case descriptions), in which 11 patient factors were systematically varied. Each care provider received a set of 12 vignettes. For each vignette, they decided whether they would give this patient self-management support and whether they expected this support to be successful. The associations between respondent decisions and patient factors were explored using ordered logit regression. Results The survey was completed by 60 general practitioners and 80 nurses. Self-management support was unlikely to be provided in a third of the vignettes. The most important patient factor in the decision to provide self-management support as well as in the expectation that self-management support would be successful was motivation, followed by patient-provider relationship and illness perception. Other factors, such as depression or anxiety, education level, self-efficacy and social support, had a small impact on decisions. Disease, disease severity, knowledge of disease, and age were relatively unimportant factors. Conclusion This is the first study to explore the relative importance of patient factors in decision making and the expectations regarding the provision of self-management support to chronic disease patients. By far, the most important factor considered was patient’s motivation; unmotivated patients

  1. How School Social Workers Use Consultation to Aid Clinical Decision Making

    ERIC Educational Resources Information Center

    Mann, Kimberly A.

    2008-01-01

    This qualitative study of school social workers who practice with youths identified as seriously emotionally disturbed offers guidelines for the use of information gleaned through consultation in clinical decision making. School social workers engage in regular consultation with professionals in the school setting, the community, the family, and…

  2. The Contribution of Polysyllabic Words in Clinical Decision Making about Children's Speech

    ERIC Educational Resources Information Center

    James, Deborah G. H.; van Doorn, Jan; McLeod, Sharynne

    2008-01-01

    Poor polysyllabic word (PSW) production seems to mark paediatric speech impairment as well as impairment in language, literacy and phonological processing. As impairment in these domains may only manifest in PSWs, PSW production may provide unique information that is often excluded from clinical decision making because insufficient PSWs are…

  3. The Value of Intelligent Multimedia Simulation for Teaching Clinical Decision-Making Skills.

    ERIC Educational Resources Information Center

    Garrett, Bernard M.; Callear, David

    2001-01-01

    Examines advantages and disadvantages of multimedia simulation in nursing education. Provides an example of a modular design with an integrated intelligent agent and knowledge base for teaching clinical decision making. Concludes that this approach overcomes some of the problems of intelligent tutoring systems. Contains 40 references. (SK)

  4. Student specialty plans, clinical decision-making, and health care reform

    PubMed Central

    Williams, Robert L.; Romney, Crystal; Kano, Miria; Wright, Randy; Skipper, Betty; Getrich, Christina; Sussman, Andrew L.; Zyzanski, Stephen J.

    2014-01-01

    Background and objectives Health care reform aims to increase evidence based, cost-conscious, and patient-centered care. Family medicine is seen as central to these aims in part due to evidence of lower cost, comparable quality care compared with other specialties. We sought evidence that senior medical students planning family medicine residency differ from peers entering other fields in decision-making patterns relevant to these health care reform aims. Methods We conducted a national, anonymous, internet-based survey of senior medical students. Students chose one of two equivalent management options for a set of patient vignettes based on preventive care, medication selection or initial chronic disease management scenarios, representing in turn, evidence-based care, cost-conscious care, and patient-centered care. We examined differences in student recommendations, comparing those planning to enter family medicine with all others using bivariate and weighted, multilevel, multivariable analyses. Results Among 4,656 surveys received from seniors at 84 participating medical schools, students entering family medicine were significantly more likely to recommend patient management options that were more cost-conscious (p=.01) and more patient-centered (p<.001). We did not find a significant difference between the student groups in recommendations for evidence-based care vignettes. Conclusions This study provides preliminary evidence suggesting that students planning to enter family practice may already have clinical decision-making patterns that support health care reform goals to a greater extent than their peers. If confirmed by additional studies, this could have implications for medical school admission and training processes. PMID:24915476

  5. Patient involvement in clinical decision making: the effect of GP attitude on patient satisfaction.

    PubMed

    Carlsen, Benedicte; Aakvik, Arild

    2006-06-01

    This study investigates general practitioners' (GPs) and patients' attitudes to shared decision making, and how these attitudes affect patient satisfaction. Sharing of information and decisions in the consultation is largely accepted as the ideal in general practice. Studies show that most patients prefer to be involved in decision making and shared decision making is associated with patient satisfaction, although preferences vary. Still we know little about how the interaction of GP and patients' attitudes affects patient satisfaction. One such study was conducted in the USA, but comparative studies are lacking. Questionnaire survey distributed through GPs. The results are based on the combined questionnaires of 41 GPs and 829 of their patients in the urban municipality of Bergen in the western part of Norway. Main variables studied The data were collected using a nine-item survey instrument constructed to measure attitudes towards patient involvement in medical consultations. The patients were also asked to rate their satisfaction with their GP. The patients had a strong preference for shared decision making. The GPs also generally preferred shared decision making, but to a lesser degree than the patients, which is the opposite of the findings of the US study. There was a positive effect of the GP's attitude towards shared decision making on patient satisfaction, but no significant effect of congruence of attitudes between patient and GP on patient satisfaction. The suggested explanation is that GPs that are positive to sharing decisions are more responsive to patients' needs and therefore satisfy patients even when the patient's attitude differs from the GPs' attitude. Hence, although some patients do prefer a passive role, it is important to promote positive attitudes towards patient involvement in medical consultations.

  6. Critical thinking and clinical decision making in critical care nursing: a pilot study.

    PubMed

    Hicks, Frank D; Merritt, Sharon L; Elstein, Arthur S

    2003-01-01

    This pilot study examined the relationship of education level, years of critical care nursing experience, and critical thinking (CT) ability (skills and dispositions) to consistency in clinical decision making among critical care nurses. Consistency was defined as the degree to which intuitive and analytical decision processes resulted in similar selection of interventions in tasks of low and high complexity. The study was nonexperimental and correlational. Critical care nurses (n = 54) from adult critical care units in 3 private teaching hospitals. The majority of nurses held a BSN or MSN and had an average of 9 years of direct clinical experience in the care of the critically ill. Decision-making consistency decreased significantly between low-complexity and high-complexity tasks. Both intuitive and analytical decision processes produced clear intervention selections in the low-complexity task, although the analytical process resulted in a more complete specification of interventions. In the high-complexity task, however, only the intuitive process resulted in a clear, plausible, and safe specification of interventions. Education and experience were not related to CT ability, nor was CT ability related to decision-making consistency. Only greater years of critical care nursing experience increased the likelihood of decision-making consistency. Overall, intuitive decision processes resulted in more clinically consistent selection of interventions across tasks. More investigation is needed to examine the influence of decision heuristics, and the conceptualization and measurement of CT abilities among practicing nurses.

  7. A clinical decision algorithm for hospital inpatients with impaired decision-making capacity.

    PubMed

    Chase, Jack

    2014-08-01

    Impaired decision-making capacity is a frequent complication of inpatient hospitalization, with potential negative impacts on patients and the healthcare system. Studies of clinician behavior show difficulty in diagnosis and management of capacity impairment. Appropriate management of incapacitated patients may benefit safety, medical outcomes, and healthcare expenditure. To create a clinical decision algorithm for identification and management of hospital inpatients with impaired capacity. The Department of Risk Management at San Francisco General Hospital (SFGH) convened a multidisciplinary workgroup to improve management of incapacitated patients. The workgroup studied institutional data and case experience, solicited mental health expertise, and performed a brief review of published tools for management of incapacitated patients. The workgroup produced a clinical decision algorithm for hospital inpatients with impaired decision-making capacity. The algorithm is explained via 3 common scenarios, and notable details include identification and management in a single visual diagram, emphasis on safety planning for a high-risk subset of incapacitated patients, and explanation for multiple disciplines of consultation. The algorithm was disseminated to providers, workshops were conducted, and associated quality improvements were implemented. Initial feedback was positive, relating to clinical competency, decreased practice anxiety, and improved teamwork. Impaired decision-making capacity is frequent among hospitalized patients, including at SFGH. An algorithm, based on institutional review and prior published work, is presented as an example to address the common challenge of acutely ill patients with impaired decision-making capacity. © 2014 Society of Hospital Medicine.

  8. 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.

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

    PubMed

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

    2016-12-01

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

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

    PubMed

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

    2017-01-01

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

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

    PubMed Central

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

    2017-01-01

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

  12. Assessing an Adolescent's Capacity for Autonomous Decision-Making in Clinical Care.

    PubMed

    Michaud, Pierre-André; Blum, Robert Wm; Benaroyo, Lazare; Zermatten, Jean; Baltag, Valentina

    2015-10-01

    The purpose of this article is to provide policy guidance on how to assess the capacity of minor adolescents for autonomous decision-making without a third party authorization, in the field of clinical care. In June 2014, a two-day meeting gathered 20 professionals from all continents, working in the field of adolescent medicine, neurosciences, developmental and clinical psychology, sociology, ethics, and law. Formal presentations and discussions were based on a literature search and the participants' experience. The assessment of adolescent decision-making capacity includes the following: (1) a review of the legal context consistent with the principles of the Convention on the Rights of the Child; (2) an empathetic relationship between the adolescent and the health care professional/team; (3) the respect of the adolescent's developmental stage and capacities; (4) the inclusion, if relevant, of relatives, peers, teachers, or social and mental health providers with the adolescent's consent; (5) the control of coercion and other social forces that influence decision-making; and (6) a deliberative stepwise appraisal of the adolescent's decision-making process. This stepwise approach, already used among adults with psychiatric disorders, includes understanding the different facets of the given situation, reasoning on the involved issues, appreciating the outcomes linked with the decision(s), and expressing a choice. Contextual and psychosocial factors play pivotal roles in the assessment of adolescents' decision-making capacity. The evaluation must be guided by a well-established procedure, and health professionals should be trained accordingly. These proposals are the first to have been developed by a multicultural, multidisciplinary expert panel. Copyright © 2015 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.

  13. 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

  14. The incremental impact of cardiac MRI on clinical decision-making.

    PubMed

    Rajwani, Adil; Stewart, Michael J; Richardson, James D; Child, Nicholas M; Maredia, Neil

    2016-01-01

    Despite a significant expansion in the use of cardiac MRI (CMR), there is inadequate evaluation of its incremental impact on clinical decision-making over and above other well-established modalities. We sought to determine the incremental utility of CMR in routine practice. 629 consecutive CMR studies referred by 44 clinicians from 9 institutions were evaluated. Pre-defined algorithms were used to determine the incremental influence on diagnostic thinking, influence on clinical management and thus the overall clinical utility. Studies were also subdivided and evaluated according to the indication for CMR. CMR provided incremental information to the clinician in 85% of cases, with incremental influence on diagnostic thinking in 85% of cases and incremental impact on management in 42% of cases. The overall incremental utility of CMR exceeded 90% in 7 out of the 13 indications, whereas in settings such as the evaluation of unexplained ventricular arrhythmia or mild left ventricular systolic dysfunction, this was <50%. CMR was frequently able to inform and influence decision-making in routine clinical practice, even with analyses that accepted only incremental clinical information and excluded a redundant duplication of imaging. Significant variations in yield were noted according to the indication for CMR. These data support a wider integration of CMR services into cardiac imaging departments. These data are the first to objectively evaluate the incremental value of a UK CMR service in clinical decision-making. Such data are essential when seeking justification for a CMR service.

  15. The incremental impact of cardiac MRI on clinical decision-making

    PubMed Central

    Stewart, Michael J; Richardson, James D; Child, Nicholas M; Maredia, Neil

    2016-01-01

    Objective: Despite a significant expansion in the use of cardiac MRI (CMR), there is inadequate evaluation of its incremental impact on clinical decision-making over and above other well-established modalities. We sought to determine the incremental utility of CMR in routine practice. Methods: 629 consecutive CMR studies referred by 44 clinicians from 9 institutions were evaluated. Pre-defined algorithms were used to determine the incremental influence on diagnostic thinking, influence on clinical management and thus the overall clinical utility. Studies were also subdivided and evaluated according to the indication for CMR. Results: CMR provided incremental information to the clinician in 85% of cases, with incremental influence on diagnostic thinking in 85% of cases and incremental impact on management in 42% of cases. The overall incremental utility of CMR exceeded 90% in 7 out of the 13 indications, whereas in settings such as the evaluation of unexplained ventricular arrhythmia or mild left ventricular systolic dysfunction, this was <50%. Conclusion: CMR was frequently able to inform and influence decision-making in routine clinical practice, even with analyses that accepted only incremental clinical information and excluded a redundant duplication of imaging. Significant variations in yield were noted according to the indication for CMR. These data support a wider integration of CMR services into cardiac imaging departments. Advances in knowledge: These data are the first to objectively evaluate the incremental value of a UK CMR service in clinical decision-making. Such data are essential when seeking justification for a CMR service. PMID:26493468

  16. 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.

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

    PubMed

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

    2014-02-01

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

  18. Evidence-based practice: how to perform and use systematic reviews for clinical decision-making.

    PubMed

    Kranke, Peter

    2010-09-01

    One approach to clinical decision-making requires the integration of the best available research evidence with individual clinical expertise and patient values, and is known as evidence-based medicine (EBM). In clinical decision-making with the current best evidence, systematic reviews have an important role. This review article covers the basic principles of systematic reviews and meta-analyses, and their role in the process of evidence-based decision-making. The problems associated with traditional narrative reviews are discussed, as well as the way systematic reviews limit bias associated with the assembly, critical appraisal and synthesis of studies addressing specific clinical questions. The relevant steps in writing a systematic review from the formulation of an initial research question to sensitivity analyses in conjunction with the combined analysis of the pooled data are described. Important issues that need to be considered when appraising a systematic review or meta-analysis are outlined. Some of the terms that are used in the reporting of systematic reviews and meta-analyses, such as relative risk, confidence interval, Forest plot or L'Abbé plot, will be introduced and explained.

  19. 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.

  20. 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.

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

    PubMed

    Taylor, Helen J

    2016-01-01

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

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

    PubMed

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

    2010-08-01

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

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

    PubMed

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

    2012-01-01

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

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

    PubMed

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

    2016-01-01

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

  5. Mock Pages Are a Valid Construct for Assessment of Clinical Decision Making and Interprofessional Communication.

    PubMed

    Boehler, Margaret L; Schwind, Cathy J; Markwell, Stephen J; Minter, Rebecca M

    2017-01-01

    Answering pages from nurses about patients in need of immediate attention is one of the most difficult challenges a resident faces during their first days as a physician. A Mock Page program has been developed and adopted into a national surgical resident preparatory curriculum to prepare senior medical students for this important skill. The purpose of this study is to assess standardized mock page cases as a valid construct to assess clinical decision making and interprofessional communication skills. Mock page cases (n = 16) were administered to 213 senior medical students from 12 medical schools participating in a national surgical resident preparatory curriculum in 2013 and 2014. Clinical decision making and interprofessional communication were measured by case-specific assessments evaluating these skills which have undergone rigorous standard-setting to determine pass/fail cut points. Students' performance improved in general for both communication and clinical decision making over the 4-week course. Cases have been identified that seem to be best suited for differentiating high- from low-performing students. Chest pain, pulmonary embolus, and mental status change cases posed the greatest difficulty for student learners. Simulated mock pages demonstrate an innovative technique for training students in both effective interprofessional communication and management of common postoperative conditions they will encounter as new surgical interns.

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

    PubMed

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

    2011-01-01

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

  7. Factors associated with clinical decision-making in relation to treatment need for temporomandibular disorders.

    PubMed

    Yekkalam, Negin; Wänman, Anders

    2016-01-01

    The aim of this study was to analyze dentist's clinical decision-making related to treatment need for temporomandibular disorders (TMD) in an adult population. The study population comprised 779 randomly selected 35, 50, 65 and 75 year old individuals living in the county of Västerbotten, Sweden. The participants filled out a questionnaire and were examined clinically according to a structured protocol. The four examiners (two men, two women) were experienced dentists and were calibrated before the start of the study. After examination they individually assessed the need of treatment owing to TMD. In total, 15% of the study population was considered to have a treatment need owing to TMD. The highest estimate was noted for 35 and 50 years old women and the lowest for 65 and 75 years old men. Overall, 21% of the women and 8% of the men were considered to have a treatment need owing to TMD, with statistically significant differences between men and women for the 35 and 50 years old groups. Inter-individual variations in dentists' decisions were observed. In a multivariate analysis, female gender, signs and symptoms of TMD pain, signs and symptoms of TMD dysfunction and smoking were associated with estimated treatment need. The prevalence of estimated treatment need owing to TMD was fairly high, but the dentists' clinical decision-making process showed large inter-individual variability. The observation calls for further research on the factors affecting the decision-making process in care providers.

  8. [Determinants of clinical decision making in primary care: opinion of physicians].

    PubMed

    Larizgoitia Jáuregui, I; Rodríguez Bermúdez, J R; Granados Navarrete, A

    1998-11-15

    The effective dissemination of scientific information and its adoption by clinicians is the desired outcome of research and the path towards evidence based clinical practice. However, the link between both ends, is not direct and not always attained. Many other determinants play decisive roles in clinical decision making. Their nature, relationship and relative importance are not well understood. We conducted a survey among primary care physicians to ascertain their perception on factors related to clinical decision making. The questionnaire was specifically developed and was administered in face to face interviews by trained interviewers. A multistage clustered sample of 800 physicians representative of all Spanish primary care physicians, was drawn out of Health Service Payroll lists. Frequencies and multivariate logistic regressions were performed using SUDAAN 7.0. Spanish physicians seem to pay special importance to organizational aspects, such as daily demand, administrative regulations or prescription costs. Expert opinion and textbooks appear as the principal source of information, systematic literature reviews are unknown for most physicians. Finally, the majority of them perceive the need for more education. Primary care physicians perceive organizational limitations to their decision making process and are willing to improve their medical knowledge. Additionally, they may benefit from strategies towards the spread of evidence based medicine built on these results, such as using experts to effectively convey evidence based information, increasing opportunities for more education, or developing evidence based sources following textbooks advantages.

  9. Mock Pages Are a Valid Construct for Assessment of Clinical Decision Making and Interprofessional Communication.

    PubMed

    Boehler, Margaret L; Schwind, Cathy J; Markwell, Stephen J; Minter, Rebecca M

    2016-01-15

    Answering pages from nurses about patients in need of immediate attention is one of the most difficult challenges a resident faces during their first days as a physician. A Mock Page program has been developed and adopted into a national surgical resident preparatory curriculum to prepare senior medical students for this important skill. The purpose of this study is to assess standardized mock page cases as a valid construct to assess clinical decision making and interprofessional communication skills. Mock page cases (n = 16) were administered to 213 senior medical students from 12 medical schools participating in a national surgical resident preparatory curriculum in 2013 and 2014. Clinical decision making and interprofessional communication were measured by case-specific assessments evaluating these skills which have undergone rigorous standard-setting to determine pass/fail cut points. Students' performance improved in general for both communication and clinical decision making over the 4-week course. Cases have been identified that seem to be best suited for differentiating high- from low-performing students. Chest pain, pulmonary embolus, and mental status change cases posed the greatest difficulty for student learners. Simulated mock pages demonstrate an innovative technique for training students in both effective interprofessional communication and management of common postoperative conditions they will encounter as new surgical interns.

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

    PubMed Central

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

    2010-01-01

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

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

    PubMed

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

    2016-01-01

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

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

    PubMed Central

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

    2016-01-01

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

  13. Untapped Potential of Observational Research to Inform Clinical Decision Making: American Society of Clinical Oncology Research Statement.

    PubMed

    Visvanathan, Kala; Levit, Laura A; Raghavan, Derek; Hudis, Clifford A; Wong, Sandra; Dueck, Amylou; Lyman, Gary H

    2017-06-01

    ASCO believes that high-quality observational studies can advance evidence-based practice for cancer care and are complementary to randomized controlled trials (RCTs). Observational studies can generate hypotheses by evaluating novel exposures or biomarkers and by revealing patterns of care and relationships that might not otherwise be discovered. Researchers can then test these hypotheses in RCTs. Observational studies can also answer or inform questions that either have not been or cannot be answered by RCTs. In addition, observational studies can be used for postmarketing surveillance of new cancer treatments, particularly in vulnerable populations. The incorporation of observational research as part of clinical decision making is consistent with the position of many leading institutions. ASCO identified five overarching recommendations to enhance the role of observational research in clinical decision making: (1) improve the quality of electronic health data available for research, (2) improve interoperability and the exchange of electronic health information, (3) ensure the use of rigorous observational research methodologies, (4) promote transparent reporting of observational research studies, and (5) protect patient privacy.

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

    PubMed

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

    2014-04-01

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

  15. 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

  16. The Three-Part Harmony of Adult Learning, Critical Thinking, and Decision-Making

    ERIC Educational Resources Information Center

    Moore, Kyle

    2010-01-01

    Adult learning, critical thinking, and decision-making are fields that receive attention individually, although they are interspersed with elements of each other's theories and philosophies. In addressing adult learning precepts, it is essential to include critical thinking and decision-making. One without the other creates weakness; all must be…

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

    PubMed

    Logan, Gemma

    2015-03-01

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

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

    PubMed Central

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

    2016-01-01

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

  19. Dysphagia evaluation practices: inconsistencies in clinical assessment and instrumental examination decision-making.

    PubMed

    Mathers-Schmidt, Barbara A; Kurlinski, Mary

    2003-01-01

    The purpose of this study was to determine the nature of swallowing evaluation practices in western Washington, specifically in terms of (a) components of the clinical examination most commonly used, (b) consistency of clinical examination practices across clinicians, and (c) consistency of clinical decision-making (instrumental vs. noninstrumental) given specific patient scenarios. A 21-question survey was sent to 150 speech-language pathologists who provide services to dysphagia patients. Of the 72 (48%) surveys that were returned, 64 provided the data for the study. The results revealed that clinicians who responded to the survey differ somewhat regarding which components they include in a clinical examination of swallowing. There was a high degree of consistency for 11 of the 19 components. Inconsistency across clinicians was revealed in four areas: assessment of sensory function, assessment of the gag reflex, cervical auscultation, and assessment of trial swallows using compensatory techniques. Clinicians agreed in their recommendations on two of the six clinical case scenarios. In general, participating clinicians varied widely in their clinical decision-making. These findings are compared with other studies where variability in clinical practice has raised concerns.

  20. Clinical Decision-Making: Heuristics and Cognitive Biases for the Ophthalmologist.

    PubMed

    Hussain, Ahsen; Oestreicher, James

    2017-08-28

    Diagnostic errors have a significant impact on healthcare outcomes and patient care. The underlying causes and development of diagnostic error is complex with flaws in healthcare systems, as well as human error, playing a role. Cognitive biases and a failure of decision-making shortcuts (heuristics) are human factors that can compromise the diagnostic process. We describe these mechanisms, their role with the clinician and provide clinical scenarios to highlight the various points at which biases may emerge. We discuss strategies to modify the development and influence of these processes, and the vulnerability of heuristics, to provide insight and improve clinical outcomes. Copyright © 2017 Elsevier Inc. All rights reserved.

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

    PubMed

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

    1995-01-01

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

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

    PubMed

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

    2015-09-01

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

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

    PubMed

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

    2011-01-01

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

  4. Newly graduated nurses' use of knowledge sources in clinical decision-making: an ethnographic study.

    PubMed

    Voldbjerg, Siri Lygum; Grønkjaer, Mette; Wiechula, Rick; Sørensen, Erik Elgaard

    2017-05-01

    To explore which knowledge sources newly graduated nurses' use in clinical decision-making and why and how they are used. In spite of an increased educational focus on skills and competencies within evidence-based practice, newly graduated nurses' ability to use components within evidence-based practice with a conscious and reflective use of research evidence has been described as being poor. To understand why, it is relevant to explore which other knowledge sources are used. This may shed light on why research evidence is sparsely used and ultimately inform approaches to strengthen the knowledgebase used in clinical decision-making. Ethnographic study using participant-observation and individual semistructured interviews of nine Danish newly graduated nurses in medical and surgical hospital settings. Newly graduates use of knowledge sources was described within three main structures: 'other', 'oneself' and 'gut feeling'. Educational preparation, transition into clinical practice and the culture of the setting influenced the knowledge sources used. The sources ranged from overt easily articulated knowledge sources to covert sources that were difficult to articulate. The limited articulation of certain sources inhibited the critical reflection on the reasoning behind decisions. Reflection is a prerequisite for an evidence-based practice where decisions should be transparent in order to consider if other evidentiary sources could be used. Although there is a complexity and variety to knowledge sources used, there is an imbalance with the experienced nurse playing a key role, functioning both as predominant source and a role model as to which sources are valued and used in clinical decision-making. If newly graduates are to be supported in an articulate and reflective use of a variety of sources, they have to be allocated to experienced nurses who model a reflective, articulate and balanced use of knowledge sources. © 2016 John Wiley & Sons Ltd.

  5. Relationships Between Clinical Decision-Making Patterns and Self-Efficacy and Nursing Professionalism in Korean Pediatric Nurses.

    PubMed

    Choi, Miyoung; Kim, Jisoo

    2015-01-01

    As pediatric nurses must make decisions on a regular basis when caring for hospitalized children, clinical decision-making abilities are necessary in this profession. In the present study, we explored clinical decision-making patterns and their association with self-efficacy and nursing professionalism in pediatric nurses. We surveyed 173 pediatric nurses and analyzed the relationships between their clinical decision-making patterns and self-efficacy and nursing professionalism. Factor analysis identified 5 clinical decision-making patterns: patient-family-nurse collaborative (PNC), individual patient-oriented (IP), nurse model-oriented (NM), pattern-oriented intuitive (PI), and nursing knowledge-oriented (NK). The most frequently observed clinical decision-making pattern was the PNC. The self-efficacy and nursing professionalism were found to be higher in pediatric nurses using the IP and NM, and were lower for those using the PNC. Thus, the present results suggest that pediatric nurses' clinical decision-making patterns are influenced by nursing professionalism and self-efficacy. Therefore, intervention programs focusing on these variables might improve clinical decision-making in pediatric nurses. Copyright © 2015 Elsevier Inc. All rights reserved.

  6. 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

  7. 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.

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

    PubMed

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

    2015-10-01

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

  9. Dissemination and Implementation of Shared Decision Making Into Clinical Practice: A Research Agenda.

    PubMed

    Kanzaria, Hemal K; Booker-Vaughns, Juanita; Itakura, Kaoru; Yadav, Kabir; Kane, Bryan G; Gayer, Christopher; Lin, Grace; LeBlanc, Annie; Gibson, Robert; Chen, Esther H; Williams, Pluscedia; Carpenter, Christopher R

    2016-12-01

    Shared decision making (SDM) is essential to advancing patient-centered care in emergency medicine. Despite many documented benefits of SDM, prior research has demonstrated persistently low levels of patient engagement by clinicians across many disciplines, including emergency medicine. An effective dissemination and implementation (D&I) framework could be used to alter the process of delivering care and to facilitate SDM in routine clinical emergency medicine practice. Here we outline a research and policy agenda to support the D&I strategy needed to integrate SDM into emergency care. © 2016 by the Society for Academic Emergency Medicine.

  10. 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

  11. Pharmacists’ Perceptions of the Influence of Interactions with the Pharmaceutical Industry on Clinical Decision-Making

    PubMed Central

    Tejani, Aaron M; Loewen, Peter; Bachand, Richard; Harder, Curtis K

    2015-01-01

    Background: There is a paucity of literature examining the perceptions of Canadian pharmacists toward drug promotion by the pharmaceutical industry and pharmacist–industry interactions. Objectives: To determine whether hospital pharmacists perceive their interactions with the pharmaceutical industry as influencing their clinical decision-making or that of their colleagues and whether hospital pharmacists perceive that interactions with the pharmaceutical industry create a conflict of interest. Methods: A cross-sectional survey of the complete sample of hospital pharmacists practising in 3 large health authorities in a single Canadian province was conducted from February to April 2010. Results: A total of 224 responses were received from the approximately 480 pharmacists in the target health authorities (response rate approximately 47%). Fifty-eight percent of respondents (127/218) did not believe that information received at industry-sponsored events influenced their clinical decision-making. Most (142/163 [87%]) disagreed that small gifts influenced their clinical decision-making, whereas responses were divided for large gifts. Respondents were also divided on the issue of whether their interactions created conflicts of interest, with most of those who had received gifts agreeing that large gifts would create a conflict of interest (134/163 [82%]) whereas small gifts would not (100/163 [61%]). There were positive correlations between respondents’ beliefs about their own susceptibility to influence from sponsored events or receipt of small or large gifts and the susceptibility of others, but 22% of respondents (28/127) expressed a different perception about sponsored events, all believing themselves to be less influenced than their colleagues. Only 6% (4/64) of those who received large gifts and 4% (5/142) of those who received small gifts and felt they were not influenced by these gifts reported that it was likely others would be influenced by the receipt of

  12. Pharmacists' Perceptions of the Influence of Interactions with the Pharmaceutical Industry on Clinical Decision-Making.

    PubMed

    Tejani, Aaron M; Loewen, Peter; Bachand, Richard; Harder, Curtis K

    2015-01-01

    There is a paucity of literature examining the perceptions of Canadian pharmacists toward drug promotion by the pharmaceutical industry and pharmacist-industry interactions. To determine whether hospital pharmacists perceive their interactions with the pharmaceutical industry as influencing their clinical decision-making or that of their colleagues and whether hospital pharmacists perceive that interactions with the pharmaceutical industry create a conflict of interest. A cross-sectional survey of the complete sample of hospital pharmacists practising in 3 large health authorities in a single Canadian province was conducted from February to April 2010. A total of 224 responses were received from the approximately 480 pharmacists in the target health authorities (response rate approximately 47%). Fifty-eight percent of respondents (127/218) did not believe that information received at industry-sponsored events influenced their clinical decision-making. Most (142/163 [87%]) disagreed that small gifts influenced their clinical decision-making, whereas responses were divided for large gifts. Respondents were also divided on the issue of whether their interactions created conflicts of interest, with most of those who had received gifts agreeing that large gifts would create a conflict of interest (134/163 [82%]) whereas small gifts would not (100/163 [61%]). There were positive correlations between respondents' beliefs about their own susceptibility to influence from sponsored events or receipt of small or large gifts and the susceptibility of others, but 22% of respondents (28/127) expressed a different perception about sponsored events, all believing themselves to be less influenced than their colleagues. Only 6% (4/64) of those who received large gifts and 4% (5/142) of those who received small gifts and felt they were not influenced by these gifts reported that it was likely others would be influenced by the receipt of such gifts. Most hospital pharmacists who

  13. Which factors play a role in clinical decision-making in external cephalic version?

    PubMed

    Kok, Marjolein; Van Der Steeg, Jan Willem; Mol, Ben W J; Opmeer, Brent; Van Der Post, Joris A

    2008-01-01

    To assess the clinical factors that influence the estimates of clinicians of the success of an external cephalic version(ECV), and the subsequent management decisions made by clinicians. We constructed 16 fictional vignettes of women with a term fetus in breech position eligible for ECV. Setting. Secondary and tertiary clinics in The Netherlands. Thirty-seven gynaecologists, residents and midwifes. Sixteen case summaries concerning a hypothetical patient eligible for ECV. Potential prognostic factors that varied between the cases were parity, maternal body mass index, engagement of the fetus, amniotic fluid, fetal growth, fetal presentation and placental localisation. For each case presentation, the clinicians were asked for their inclination to perform an ECV, and whether or not they would use tocolysis. The estimated probabilities of success varied between 20 and 60%. The number of clinicians that would attempt an ECV varied per case between 32 and 97%. Amniotic fluid and engagement contributed 80% of the variation in the decision to perform ECV. In the case of oligohydramnios or an engaged breech, the clinicians tended not to perform an ECV. Amniotic fluid and engagement seem to be the main factors in the clinical decision-making of clinicians in ECV.This decision-making is probably experience based. Systematic knowledge of clinical prognosticators and subsequent assessment of their prognostic capacity is needed.

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

    PubMed

    Edelen, Bonnie Gilbert; Bell, Alexandra Alice

    2011-08-01

    The purpose of this study was to address the need for effective educational interventions to promote students' clinical decision making (CDM) within clinical practice environments. Researchers used a quasi-experimental, non-equivalent groups, posttest-only design to assess differences in CDM ability between intervention group students who participated in analogy-guided learning activities and control group students who participated in traditional activities. For the intervention, analogy-guided learning activities were incorporated into weekly group discussions, reflective journal writing, and questioning with clinical faculty. The researcher-designed Assessment of Clinical Decision Making Rubric was used to assess indicators of CDM ability in all students' reflective journal entries. Results indicated that the intervention group demonstrated significantly higher levels of CDM ability in their journals compared with the control group (ES(sm) = 0.52). Recommendations provide nurse educators with strategies to maximize students' development of CDM ability, better preparing students for the demands they face when they enter the profession. Copyright 2011, SLACK Incorporated.

  15. 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

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

    PubMed

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

    2016-12-01

    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. 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. 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. The results of this study support the use of the TWED checklist to facilitate metacognition in clinical decision-making.

  17. Patient exposure in the basic science classroom enhances differential diagnosis formation and clinical decision-making.

    PubMed

    Peacock, Justin G; Grande, Joseph P

    2015-01-01

    Purpose. The authors proposed that introducing real patients into a pathology classroom early in medical education would help integrate fundamental principles and disease pathology with clinical presentation and medical history. Methods. Three patients with different pathologies described their history and presentation without revealing their diagnosis. Students were required to submit a differential diagnosis in writing, and then were able to ask questions to arrive at the correct diagnosis. Students were surveyed on the efficacy of patient-based learning. Results. Average student scores on the differential diagnosis assignments significantly improved 32% during the course. From the survey, 72% of students felt that patient encounters should be included in the pathology course next year. Seventy-four percent felt that the differential diagnosis assignments helped them develop clinical decision-making skills. Seventy-three percent felt that the experience helped them know what questions to ask patients. Eighty-six percent felt that they obtained a better understanding of patients' social and emotional challenges. Discussion. Having students work through the process of differential diagnosis formulation when encountering a real patient and their clinical presentation improved clinical decision-making skills and integrated fundamental concepts with disease pathology during a basic science pathology course.

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

    PubMed Central

    Nicholson, W Reg

    1998-01-01

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

  19. Functional Assessment of Genetic Variants with Outcomes Adapted to Clinical Decision-Making

    PubMed Central

    Thouvenot, Pierre; Ben Yamin, Barbara; Fourrière, Lou; Lescure, Aurianne; Boudier, Thomas; Del Nery, Elaine; Chauchereau, Anne; Goldgar, David E.; Stoppa-Lyonnet, Dominique; Nicolas, Alain; Millot, Gaël A.

    2016-01-01

    Understanding the medical effect of an ever-growing number of human variants detected is a long term challenge in genetic counseling. Functional assays, based on in vitro or in vivo evaluations of the variant effects, provide essential information, but they require robust statistical validation, as well as adapted outputs, to be implemented in the clinical decision-making process. Here, we assessed 25 pathogenic and 15 neutral missense variants of the BRCA1 breast/ovarian cancer susceptibility gene in four BRCA1 functional assays. Next, we developed a novel approach that refines the variant ranking in these functional assays. Lastly, we developed a computational system that provides a probabilistic classification of variants, adapted to clinical interpretation. Using this system, the best functional assay exhibits a variant classification accuracy estimated at 93%. Additional theoretical simulations highlight the benefit of this ready-to-use system in the classification of variants after functional assessment, which should facilitate the consideration of functional evidences in the decision-making process after genetic testing. Finally, we demonstrate the versatility of the system with the classification of siRNAs tested for human cell growth inhibition in high throughput screening. PMID:27272900

  20. Valuing structured professional judgment: predictive validity, decision-making, and the clinical-actuarial conflict.

    PubMed

    Falzer, Paul R

    2013-01-01

    Structured professional judgment (SPJ) has received considerable attention as an alternative to unstructured clinical judgment and actuarial assessment, and as a means of resolving their ongoing conflict. However, predictive validity studies have typically relied on receiver operating characteristic (ROC) analysis, the same technique commonly used to validate actuarial assessment tools. This paper presents SPJ as distinct from both unstructured clinical judgment and actuarial assessment. A key distinguishing feature of SPJ is the contribution of modifiable factors, either dynamic or protective, to summary risk ratings. With modifiable factors, the summary rating scheme serves as a prognostic model rather than a classification procedure. However, prognostic models require more extensive and thorough predictive validity testing than can be provided by ROC analysis. It is proposed that validation should include calibration and reclassification techniques, as well as additional measures of discrimination. Several techniques and measures are described and illustrated. The paper concludes by tracing the limitations of ROC analysis to its philosophical foundation and its origin as a statistical theory of decision-making. This foundation inhibits the performance of crucial tasks, such as determining the sufficiency of a risk assessment and examining the evidentiary value of statistical findings. The paper closes by noting a current effort to establish a viable and complementary relationship between SPJ and decision-making theory.

  1. 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

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

    PubMed

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

    2011-04-01

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

  3. Value of information methods for planning and analyzing clinical studies optimize decision making and research planning.

    PubMed

    Willan, Andrew R; Goeree, Ron; Boutis, Kathy

    2012-08-01

    The results of two randomized clinical trials (RCTs) demonstrate the clinical effectiveness of alternatives to casting for certain ankle and wrist fractures. We illustrate the use of value of information (VOI) methods for evaluating the evidence provided by these studies with respect to decision making. Using cost-effectiveness data from these studies, the expected value of sample information (EVSI) of a future RCT can be determined. If the EVSI exceeds the cost of the future trial for any sample size, then the current evidence is considered insufficient for decision making and a future trial is considered worthwhile. If, on the other hand, there is no sample size for which the EVSI exceeds the cost, then the evidence is considered sufficient, and no future trial is required. We found that the evidence from the ankle study was insufficient to support the adoption of the removable device and determined the optimal sample size for a future trial. Conversely, the evidence from the wrist study was sufficient to support the adoption of the removable device. VOI methods provide a decision-analytic alternative to the standard hypothesis testing approach for assessing the evidence provided by cost-effectiveness studies and for determining sample sizes for RCTs. Copyright © 2012 Elsevier Inc. All rights reserved.

  4. Differing levels of clinical evidence: exploring communication challenges in shared decision making. Introduction.

    PubMed

    Smith, Quentin W; Street, Richard L; Volk, Robert J; Fordis, Michael

    2013-02-01

    The near ubiquitous access to information is transforming the roles and relationships among clinical professionals, patients, and their care givers in nearly all aspects of healthcare. Informed patients engage their physicians in conversations about their conditions, options and the tradeoffs among diagnostic and therapeutic benefits and harms. The processes of care today increasingly and explicitly integrate exploration of patient values and preferences as patients and clinicians jointly engage in reaching decisions about care. The informed patient of today who can understand and use scientific information can participate as an equal partner with her clinician. Others with beliefs or educational, cultural, or literacy backgrounds that pose challenges to comprehending and applying evidence may face disenfranchisement. These barriers are significant enough, even in the face of certainty of evidence, that clinicians and investigators have given much thought to how best to engage all patients in decision making. However, barriers remain, as most decision making must occur in settings where uncertainty, if not considerable uncertainty, accompanies any statement of what we know. In September 2011, health care and health communication experts came together in Rockville, Maryland under the auspices of the Agency for Healthcare Research and Quality (AHRQ) John M. Eisenberg Center for Clinical Decisions and Communications Science Annual Meeting to explore the challenges of differing levels of evidence in promoting shared decisions and to propose strategies for going forward in addressing these challenges. Eight scholarly papers emerged, and with this introductory article, comprise this special issue of Medical Care Research and Review.

  5. Referral of surgical patients to an anaesthetic clinic: a decision-making analysis.

    PubMed

    Lee, A; Lum, M E; Hillman, K M; Bauman, A

    1994-10-01

    Effective utilization of an anaesthetic clinic depends on appropriate referral of high-risk surgical patients. The decision-making behaviour of anaesthetists and nurses was examined to identify factors that influence the referral of patients to an outpatient anaesthetic clinic. Eleven consultant anaesthetists, seven anaesthetic trainees and sixteen nurses working in anaesthetic areas estimated the likelihood that they would refer patients for each of the 30 scenarios presented. The relative importance of each factor influencing the decision to refer as determined by the 34 participants were: type of procedure (22%), co-morbidities (18%), fitness (13%), history of anaesthetic problems (12%), medications (11%), age (10%), obesity (8%) and anxiety (6%). Indicative risk factors identified were aged 65 years or over, unable to climb more than two flights of stairs, presence of significant medical problems, gross obesity, history of anaesthetic problems, taking regular medications, scheduled for major surgery and expressed anxiety about the anaesthetic. There were large variations in the decision-making behaviour among health professional groups.

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

    PubMed

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

    2016-10-01

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

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

    PubMed Central

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

    2016-01-01

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

  8. 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

  9. Clinical intuition in the nursing process and decision-making-A mixed-studies review.

    PubMed

    Melin-Johansson, Christina; Palmqvist, Rebecca; Rönnberg, Linda

    2017-03-22

    To review what is characteristic of registered nurses' intuition in clinical settings, in relationships and in the nursing process. Intuition is a controversial concept and nurses believe that there are difficulties in how they should explain their nursing actions or decisions based on intuition. Much of the evidence from the body of research indicates that nurses value their intuition in a variety of clinical settings. More information on how nurses integrate intuition as a core element in daily clinical work would contribute to an improved understanding on how they go about this. Intuition deserves a place in evidence-based activities, where intuition is an important component associated with the nursing process. An integrative review strengthened with a mixed-studies review. Literature searches were conducted in the databases CINAHL, PubMed and PsycINFO, and literature published 1985-2016 were included. The findings in the studies were analysed with content analysis, and the synthesis process entailed a reasoning between the authors. After a quality assessment, 16 studies were included. The analysis and synthesis resulted in three categories. The characteristics of intuition in the nurse's daily clinical activities include application, assertiveness and experiences; in the relationships with patients' intuition include unique connections, mental and bodily responses, and personal qualities; and in the nursing process include support and guidance, component and clues in decision-making, and validating decisions. Intuition is more than simply a "gut feeling," and it is a process based on knowledge and care experience and has a place beside research-based evidence. Nurses integrate both analysis and synthesis of intuition alongside objective data when making decisions. They should rely on their intuition and use this knowledge in clinical practice as a support in decision-making, which increases the quality and safety of patient care. We find that intuition plays a

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

    PubMed

    Ambigapathy, Ranjini; Chia, Yook Chin; Ng, Chirk Jenn

    2016-01-04

    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. A cross-sectional study. Study was conducted at an urban primary care clinic in Malaysia in 2012. Patients aged >21 years were chosen using systematic random sampling. 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. Prevalence of patients' preferred role in decision-making. (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. 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). 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. 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/

  11. Principles of educational outreach ('academic detailing') to improve clinical decision making.

    PubMed

    Soumerai, S B; Avorn, J

    1990-01-26

    With the efficacy and costs of medications rising rapidly, it is increasingly important to ensure that drugs be prescribed as rationally as possible. Yet, physicians' choices of drugs frequently fall short of the ideal of precise and cost-effective decision making. Evidence indicates that such decisions can be improved in a variety of ways. A number of theories and principles of communication and behavior changes can be found that underlie the success of pharmaceutical manufacturers in influencing prescribing practices. Based on this behavioral science and several field trials, it is possible to define the theory and practice of methods to improve physicians' clinical decision making to enhance the quality and cost-effectiveness of care. Some of the most important techniques of such "academic detailing" include (1) conducting interviews to investigate baseline knowledge and motivations for current prescribing patterns, (2) focusing programs on specific categories of physicians as well as on their opinion leaders, (3) defining clear educational and behavioral objectives, (4) establishing credibility through a respected organizational identity, referencing authoritative and unbiased sources of information, and presenting both sides of controversial issues, (5) stimulating active physician participation in educational interactions, (6) using concise graphic educational materials, (7) highlighting and repeating the essential messages, and (8) providing positive reinforcement of improved practices in follow-up visits. Used by the nonprofit sector, the above techniques have been shown to reduce inappropriate prescribing as well as unnecessary health care expenditures.

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

    PubMed Central

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

    2016-01-01

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

  13. Best practices: a program to support shared decision making in an outpatient psychiatric medication clinic.

    PubMed

    Deegan, Patricia E; Rapp, Charles; Holter, Mark; Riefer, Melody

    2008-06-01

    This column presents preliminary findings of an intervention to support shared decision making in psychopharmacology consultation. The waiting area in an urban psychiatric medication clinic was transformed into a peer-run Decision Support Center featuring a user-friendly, Internet-based software program with which clients could create a one-page computer-generated report for use in the medication consultation. The Decision Support Center was used 662 times by 189 unique users from a young-adult and general adult case management team from October 2006 to September 2007. All clients had severe mental disorders. Only ten clients refused to use the intervention at some point during the pilot study. Focus groups with medical staff (N=4), clients (N=16), case managers (N=14), and peer-specialist staff (N=3) reported that the intervention helped to create efficiencies in the consultation and empower clients to become more involved in treatment-related decision making. A randomized controlled trial is currently in process.

  14. Antecedents of ethical decision-making: intercollegiate sporting environments as clinical education and practice settings.

    PubMed

    Caswell, Shane V; Ambegaonkar, Jatin P; Caswell, Amanda M; Gould, Trenton E

    2009-01-01

    Unique among allied health care professions, athletic training is predominately practiced amid competitive intercollegiate sports. Competitive sporting environments have been suggested to adversely impact morality, ethical decision-making (EDM), and behavior. The purposes of this study were to (1) investigate the effect of institutional National Collegiate Athletic Association (NCAA) participation level on preferred ethical ideologies and EDM, (2) determine the relationship between professional status (athletic training student [ATS] or certified athletic trainer [ATC]) and ethical ideology preferences and EDM, and (3) examine whether preferred ethical ideology is related to differences in EDM. A nationally representative sample of 610 ATSs and ATCs from 30 athletic training education programs, stratified by NCAA division level, participated in the study. All participants completed a demographic survey, the Ethics Position Questionnaire, and the Dilemmas in Athletic Training Questionnaire. No significant relationships were noted between NCAA participation level and respondents' ethical ideology preferences. However, ATSs and ATCs demonstrated significant preferences for specific ethical ideologies, with students adopting the subjectivist ideology more than expected and the exceptionist ideology less than expected and ATCs adopting the exceptionist ideology more than expected and the situationist ideology less than expected. In contrast to some previous research, our results suggest that competitive sporting environments do not affect ATSs' and ATCs' ethical ideology and EDM abilities at the collegiate level. These findings serve as a baseline for future research examining the ethical ideologies and ethical decision-making levels of athletic training practitioners and other allied health professionals across clinical settings.

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

    PubMed

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

    2016-11-19

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

  16. 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

  17. [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.

  18. Reasoning, evidence, and clinical decision-making: The great debate moves forward.

    PubMed

    Loughlin, Michael; Bluhm, Robyn; Buetow, Stephen; Borgerson, Kirstin; Fuller, Jonathan

    2017-10-01

    When the editorial to the first philosophy thematic edition of this journal was published in 2010, critical questioning of underlying assumptions, regarding such crucial issues as clinical decision making, practical reasoning, and the nature of evidence in health care, was still derided by some prominent contributors to the literature on medical practice. Things have changed dramatically. Far from being derided or dismissed as a distraction from practical concerns, the discussion of such fundamental questions, and their implications for matters of practical import, is currently the preoccupation of some of the most influential and insightful contributors to the on-going evidence-based medicine debate. Discussions focus on practical wisdom, evidence, and value and the relationship between rationality and context. In the debate about clinical practice, we are going to have to be more explicit and rigorous in future in developing and defending our views about what is valuable in human life. © 2017 John Wiley & Sons, Ltd.

  19. Clinical dilemmas in children with life-limiting illnesses: decision making and the law.

    PubMed

    Wright, B; Aldridge, J; Wurr, K; Sloper, T; Tomlinson, H; Miller, M

    2009-04-01

    Decision making about interventions for children and young people with life-limiting illnesses is fraught with difficulties but faced regularly by staff in children's hospices and paediatric wards. The perspectives of the child, various family members and professionals may all be different. The process of discussion and negotiation and the mechanism by which a decision is arrived at is complex. Various laws have recently changed in the UK that have an impact on this process. This article discusses several clinical scenarios to better understand these decisions and the effects of changes in the law. It also discusses how multidisciplinary teams in children's hospices (and other supportive clinical systems) can best support young people and families with and without recourse to the law.

  20. Clinical presentations of critical cardiac defects in the newborn: Decision making and initial management

    PubMed Central

    2010-01-01

    The risk of mortality and morbidity of patients with congenital heart defects (CHDs) is highest during neonatal period and increases when diagnosis and proper management are delayed. Neonates with critical CHDs may present with severe cyanosis, respiratory distress, shock, or collapse, all of which are also frequent clinical presentations of various respiratory problems or sepsis in the newborn. Early diagnosis and stabilization and timely referral to a tertiary cardiac center are crucial to improve the outcomes in neonates with CHDs. In this review, the clinical presentation of critical and potentially life-threatening CHDs is discussed along with brief case reviews to help understand the hemodynamics of these defects and ensure proper decision-making in critically ill patients. PMID:21189937

  1. Intelligent dialogue based on statistical models of clinical decision-making.

    PubMed

    McSherry, D M

    1986-01-01

    The independence Bayesian model has been used widely in computer programs designed to support clinical decision-making. A reasoning strategy has been developed to enable these programs to conduct clinically pertinent dialogue and explain their reasoning. It has been implemented in a program for the diagnosis of acute abdominal pain based on the Bayesian model of de Dombal et al. Several features of the dialogue design have been adopted from artificial intelligence research, including shared initiative and critiquing. The program adopts a flexible goal-driven strategy, attempting to confirm the clinician's diagnosis or rule out the likeliest alternative. Symptoms and signs are selected in order of their expected weights of evidence in favour of the hypothesized disease.

  2. Decision making.

    PubMed

    Chambers, David W

    2011-01-01

    A decision is a commitment of resources under conditions of risk in expectation of the best future outcome. The smart decision is always the strategy with the best overall expected value-the best combination of facts and values. Some of the special circumstances involved in decision making are discussed, including decisions where there are multiple goals, those where more than one person is involved in making the decision, using trigger points, framing decisions correctly, commitments to lost causes, and expert decision makers. A complex example of deciding about removal of asymptomatic third molars, with and without an EBD search, is discussed.

  3. Clinical decision-making in multiple sclerosis: Challenges reported internationally with emerging treatment complexity.

    PubMed

    Ng, Pamela; Murray, Suzanne; Hayes, Sean M

    2015-07-01

    The introduction of several new disease-modifying therapies (DMTs) to the field of Multiple Sclerosis (MS) treatment requires that MS healthcare providers have a comprehensive understanding of the implications of each new treatment option in order to select the treatment that best suits their patient. An international study was conducted in 6 countries to obtain a better understanding of the issues and challenges experienced by Neurologists and Nurses in the treatment and management of their patients with MS. The goal of this research was to obtain evidence to inform future Continuing Medical Education (CME) initiatives and health policies that promote knowledge translation to clinical practice. This article focuses on challenges reported in relation to the use of newly approved therapies, in light of the risks of these new treatments, as well as screening and monitoring precautions that must be taken. An exploratory study and literature review informed the design of an IRB-approved online survey deployed to MS Neurologists and Nurses practicing in 6 countries (Germany, France, Italy, Spain, UK, USA). The sample consisted of actively practicing Neurologists (n=156) and Nurses (n=153). Substantive challenges were reported in participant's knowledge of and confidence in three categories: i) safety profile of newly approved therapies, ii) screening patients for treatment with newly approved therapies, and iii) monitoring for serious adverse events. Findings indicate that, internationally, healthcare providers report substantive challenges integrating newly approved therapies into their clinical decision-making. This study highlights potential factors underlying the challenges, and identifies important targets for CME interventions and policymakers to enhance clinical decision-making amongst MS providers. Copyright © 2015 Elsevier B.V. All rights reserved.

  4. Successful Clinical Trial Research in Nursing Homes: The Improving Decision-Making Study

    PubMed Central

    Hanson, Laura C.; Gilliam, Robin; Lee, Tae Joon

    2015-01-01

    Background One in four Americans, and 70% of people who have dementia, will spend their final days in nursing home care. Clinical research, particularly clinical trials, rarely includes this population due to unique challenges in research methods and ethics. Families of advanced dementia patients make choices about tube feeding and other feeding options with limited access to information or communication. The cluster randomized trial, Improving Decision Making about Feeding Options for Dementia Patients, tests a decision aid intervention to improve the quality of decision making for this choice. Purpose Our objectives are 1) to describe the methods used in this trial; 2) to describe challenges and strategies for effective nursing home and nursing home resident recruitment and retention; and 3) to describe research ethics approaches to minimize harms and maximize benefits for this population. Methods The study is a cluster randomized trial of a decision aid to inform and support the choice between tube feeding and assisted oral feeding in advanced dementia. Study subjects are paired surrogate decision-makers and residents with advanced dementia and feeding problems, enrolled from nursing homes in North Carolina. Results This trial enrolled 256 paired surrogate decision-makers and residents in 24 nursing home sites, and 99% completed participation through the 3-month study period. The research team had prior clinical and investigative experience in this setting, and used multiple strategies to recruit and retain nursing home sites, providers, surrogates and the residents for whom they spoke. Informed consent and human subjects protections were designed to address the vulnerability of this population. Limitations Cluster randomization was necessary to avoid contamination between control and intervention subjects, but may introduce confounding by site and intra-class correlation effects in analyses. Conclusions Strategies that facilitate nursing home recruitment, study

  5. [An expert system of aiding decision making in breast pathology connected to a clinical data base].

    PubMed

    Brunet, M; Durrleman, S; Ferber, J; Ganascia, J G; Hacene, K; Hirt, F; Jouniaux, F; Meeus, L

    1987-01-01

    The René Huguenin Cancer Center holds a medical file for each patient which is intended to store and process medical data. Since 1970, we introduced computerization: a development plan was elaborated and simultaneously a statistical software (Clotilde--GSI/CFRO) was selected. Thus, we now have access to a large database, structured according to medical rationale, and utilizable with methods of artificial intelligence towards three objectives: improved data acquisition, decision making and exploitation. The first application was to breast pathology, which represents one of the Center's primary activities. The structure of the data concerning patients is by all criteria part of the medical knowledge. This information needs to be presented as well as processed with a suitable language. To this end, we chose a language-oriented object, Mering II, usable with Apple and IBM 4 micro-computers. This project has already allowed to work out an operational model.

  6. Patients' Perceptions and Experiences of Shared Decision-Making in Primary HIV Care Clinics.

    PubMed

    Fuller, Shannon M; Koester, Kimberly A; Guinness, Ryan R; Steward, Wayne T

    Shared decision-making (SDM) is considered best practice in health care. Prior studies have explored attitudes and barriers/facilitators to SDM, with few specific to HIV care. We interviewed 53 patients in HIV primary care clinics in California to understand the factors and situations that may promote or hinder engagement in SDM. Studies in other populations have found that patients' knowledge about their diseases and their trust in providers facilitated SDM. We found these features to be more nuanced for HIV. Perceptions of personal agency, knowledge about one's disease, and trust in provider were factors that could work for or against SDM. Overall, we found that participants described few experiences of SDM, especially among those with no comorbidities. Opportunities for SDM in routine HIV care (e.g., determining antiretroviral therapy) may arise infrequently because of treatment advances. These findings yield considerations for adapting SDM to fit the context of HIV care.

  7. An Investigation of Factors Influencing Nurses' Clinical Decision-Making Skills.

    PubMed

    Wu, Min; Yang, Jinqiu; Liu, Lingying; Ye, Benlan

    2016-08-01

    This study aims to investigate the influencing factors on nurses' clinical decision-making (CDM) skills. A cross-sectional nonexperimental research design was conducted in the medical, surgical, and emergency departments of two university hospitals, between May and June 2014. We used a quantile regression method to identify the influencing factors across different quantiles of the CDM skills distribution and compared the results with the corresponding ordinary least squares (OLS) estimates. Our findings revealed that nurses were best at the skills of managing oneself. Educational level, experience, and the total structural empowerment had significant positive impacts on nurses' CDM skills, while the nurse-patient relationship, patient care and interaction, formal empowerment, and information empowerment were negatively correlated with nurses' CDM skills. These variables explained no more than 30% of the variance in nurses' CDM skills and mainly explained the lower quantiles of nurses' CDM skills distribution. © The Author(s) 2016.

  8. Colon trauma--clinical staging for surgical decision making. Analysis of 119 cases.

    PubMed

    Morgado, P J; Alfaro, R; Morgado, P J; León, P

    1992-10-01

    A retrospective study is presented of 119 patients admitted to the Central Hospital of the Venezuelan Institute of Social Security, in Caracas, between 1982 and 1990, with the diagnosis of colon trauma. Several parameters including age, etiology, time elapsed between the accident or assault and hospital admission, preoperative and postoperative hemoglobin and diastolic blood pressure, associated lesions, procedure practiced, complication rate, and hospital mortality are reviewed. The second and third decades of life appear most often involved. Most patients reached the hospital within the first four hours of the accident or assault. Anemia, sustained diastolic hypotension, and number of organs involved in addition to the colon were important prognostic factors for complications. Apparently the surgical procedure, with simple suture or resection, mostly without "protective" colostomy, was not very relevant. Hospital mortality was 2.4 percent. A staging system based on clinical conditions for decision making in the operating room was used in an attempt to inject some objectivity into the surgical approach.

  9. The value of intelligent multimedia simulation for teaching clinical decision-making skills.

    PubMed

    Garrett, B M; Callear, D

    2001-07-01

    This paper examines the value of using intelligent multimedia simulation for the teaching of nursing clinical decision-making skills. The possibilities of multimedia-based educational resources are examined and the rapid growth and questionable effectiveness of current multimedia computer-based learning applications for nursing students are discussed. The advantages and disadvantages of this technology and the problems developing intelligent agent-based systems are examined. A case study is presented which uses a modular design with an integrated intelligent agent and knowledge base. It is argued that by using this type of approach, the real value of intelligent CBL to provide individual formative advice to students in a simulated experience can be realized. Copyright 2001 Harcourt Publishers Ltd.

  10. When to cut? Using an objective structured clinical examination to evaluate surgical decision-making.

    PubMed

    Franzese, Christine

    2007-11-01

    To create an objective structured clinical examination (OSCE) tailored to surgical residents that uses surgical case scenarios appropriate for the experience level of the resident to evaluate whether residents understand the indications for a specific surgery, identify when indications are met, and make the appropriate decision to proceed with an operation. The surgical OSCE consisted of two case scenarios: a junior case created for postgraduate year (PGY) 2 to 3 level residents and a senior case created for PGY 4 to 5 level residents. Four senior residents and four junior residents in the otolaryngology department participated. Residents were instructed to proceed as if they had all the capabilities of the otolaryngology clinic. Recordings were made of each encounter and were reviewed by two separate faculty member with expertise in each case. Faculty evaluated whether surgical indications were elicited by history, whether certain physical examination or radiographic findings were recognized, whether residents made the correct diagnosis, and whether residents not only made the decision to proceed with surgery but also indicated the correct surgery. Seniors (100%) were better at obtaining needed surgical information and indications than juniors (25%). Seniors were more willing to make the decision to proceed with surgery (100%), whereas no juniors actually scheduled surgery. The reasons for this ranged from failure to elicit surgical indications to lack of surety in proceeding with surgery. All seniors recommended the appropriate surgery, but only 75% correctly identified the need for emergent intervention. Results of evaluations were reviewed with each resident individually. The surgical OSCE was successful in evaluating resident surgical decision-making. Juniors were not as capable as seniors in eliciting surgical indications and in "making the jump" to proceed with surgery. These results were used by our faculty to work with juniors on surgical history

  11. Comparing the Effectiveness of Alerts and Dynamically Annotated Visualizations (DAVs) in Improving Clinical Decision Making.

    PubMed

    Rayo, Michael F; Kowalczyk, Nina; Liston, Beth W; Sanders, Elizabeth B-N; White, Susan; Patterson, Emily S

    2015-09-01

    The aim of this study was to compare the effectiveness of two types of real-time decision support, an interrupting pop-up alert and a noninterrupting dynamically annotated visualization (DAV), in reducing clinically inappropriate diagnostic imaging orders. Alerts in electronic health record software are frequently disregarded due to high false-alarm rates, interruptions, and uncertainty about what triggered the alert. In other settings, providing visualizations and improving understandability of the guidance has been shown to improve overall decision making. Using a between-subject design, we examined the effect of two forms of decision support, alerts and DAVs, on reducing the proportion of inappropriate diagnostic imaging orders for 11 patients in a simulated environment. Nine attending and 11 resident physicians with experience using an electronic health record were randomly assigned to the form of decision support. Secondary measures were self-reported understandability, algorithm transparency, and clinical relevance. Fewer inappropriate diagnostic imaging tests were ordered with DAVs than with alerts (18% vs. 34%, p < .001). The DAV was rated higher for all three secondary measures (p < .001) for all participants. DAVs were more effective than alerts in reducing inappropriate imaging orders and were preferred for all patient scenarios, especially scenarios where guidance was ambiguous or based on inaccurate information. Creating visualizations that are permanently displayed and vary in the strength of their guidance can mitigate the risk of system performance degradation due to incomplete or incorrect data. This interaction paradigm may be applicable for other settings with high false-alarm rates or where there is a need to reduce interruptions during decision making. © 2015, Human Factors and Ergonomics Society.

  12. Nurses' clinical decision-making for preserving nursing home residents' remaining abilities.

    PubMed

    Kim, Hyun Ju; Choi, Jung Eun; Kim, Mi So; Kim, Su Jin; Chang, Sung Ok

    2016-05-01

    This study was conducted to clarify and conceptualise nurses' clinical decision-making for preserving the remaining abilities of nursing home residents suffering from physical-cognitive functional decline. Older adults experience physical, psychological and social changes, but their remaining abilities differ across individuals. This study used a qualitative research to gain a deeper understanding of nursing homes nurses' clinical decision-making. In-depth interviews with 32 experienced nurses were undertaken. The data were analysed using conventional content analysis. Six categories and 58 subcategories of nursing practice related to managing the remaining abilities of residents with physical-cognitive functional decline were generated. The results of this study revealed five themes: (1) seeing residents' potential, (2) physical, emotional and psychosocial care in daily routines, (3) keeping personalised charts, (4) encouraging, promoting and physical and emotional support and (5) preparing residents for more independent living. The results were categorised into nurses' personal strategies based on their experience, practical nursing knowledge, nursing interventions and nursing evaluation criteria. The themes reflected positive views on the residents' functional abilities and the nursing homes nurses' perception that their goal was to help residents achieve their highest level of independence. Preserving nursing home residents' remaining abilities represents nurses' optimistic view of residents' functional status. Routine care tailored for preserving the remaining abilities of individual nursing home residents with physical-cognitive functional decline is needed. Preserving the remaining abilities of nursing home resident is supported by therapeutic interactions including close contact as well as physical and emotional support. Nurses' main goal in working with residents with remaining abilities is improving their independence. © 2016 John Wiley & Sons Ltd.

  13. 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.

  14. Clinical decision making and outcome in the routine care of people with severe mental illness across Europe (CEDAR).

    PubMed

    Puschner, B; Becker, T; Mayer, B; Jordan, H; Maj, M; Fiorillo, A; Égerházi, A; Ivánka, T; Munk-Jørgensen, P; Krogsgaard Bording, M; Rössler, W; Kawohl, W; Slade, M

    2016-02-01

    Shared decision making has been advocated as a means to improve patient-orientation and quality of health care. There is a lack of knowledge on clinical decision making and its relation to outcome in the routine treatment of people with severe mental illness. This study examined preferred and experienced clinical decision making from the perspectives of patients and staff, and how these affect treatment outcome. "Clinical Decision Making and Outcome in Routine Care for People with Severe Mental Illness" (CEDAR; ISRCTN75841675) is a naturalistic prospective observational study with bimonthly assessments during a 12-month observation period. Between November 2009 and December 2010, adults with severe mental illness were consecutively recruited from caseloads of community mental health services at the six study sites (Ulm, Germany; London, UK; Naples, Italy; Debrecen, Hungary; Aalborg, Denmark; and Zurich, Switzerland). Clinical decision making was assessed using two instruments which both have parallel patient and staff versions: (a) The Clinical Decision Making Style Scale (CDMS) measured preferences for decision making at baseline; and (b) the Clinical Decision Making Involvement and Satisfaction Scale (CDIS) measured involvement and satisfaction with a specific decision at all time points. Primary outcome was patient-rated unmet needs measured with the Camberwell Assessment of Need Short Appraisal Schedule (CANSAS). Mixed-effects multinomial regression was used to examine differences and course over time in involvement in and satisfaction with actual decision making. The effect of clinical decision making on the primary outcome was examined using hierarchical linear modelling controlling for covariates (study centre, patient age, duration of illness, and diagnosis). Analysis were also controlled for nesting of patients within staff. Of 708 individuals approached, 588 adults with severe mental illness (52% female, mean age = 41.7) gave informed consent. Paired

  15. Feasibility and efficacy of shared decision making for first-admission schizophrenia: a randomized clinical trial.

    PubMed

    Ishii, Mio; Okumura, Yasuyuki; Sugiyama, Naoya; Hasegawa, Hana; Noda, Toshie; Hirayasu, Yoshio; Ito, Hiroto

    2017-02-06

    The feasibility of shared decision making (SDM) for patients with schizophrenia remains controversial due to the assumed inability of patients to cooperate in treatment decision making. This study evaluated the feasibility and efficacy of SDM in patients upon first admission for schizophrenia. This was a randomized, parallel-group, two-arm, open-label, single-center study conducted in an acute psychiatric ward of Numazu Chuo Hospital, Japan. Patients with the diagnosis of schizophrenia upon their first admission were randomized into a SDM intervention group or a usual treatment group in a 1:1 ratio. The primary outcome was patient satisfaction at discharge. The secondary outcomes were attitudes toward medication at discharge and treatment continuation at 6 months after discharge. Twenty-four patients were randomly assigned. The trial was prematurely terminated due to slow enrollment. At discharge, the mean score on satisfaction was 23.7 in the SDM group and 22.1 in the usual care group (unadjusted mean difference: 1.6; 95% CI: -5.2 to 2.0). Group differences were not observed in attitude toward medication and treatment continuation. There was no statistically significant difference between the groups for the mean Global Assessment of Functioning score at discharge or length of stay as safety endpoint. No statistical differences were found between the SDM group and usual care group in the efficacy outcomes and safety endpoints. Large trials are needed to confirm the efficacy of the SDM program upon first admission for schizophrenia. The study has been registered with ClinicalTrials.gov as NCT01869660 (registered 27 May, 2013).

  16. Implementing shared decision-making in nutrition clinical practice: A theory-based approach and feasibility study

    PubMed Central

    Desroches, Sophie; Gagnon, Marie-Pierre; Tapp, Sylvie; Légaré, France

    2008-01-01

    Background There are a growing number of dietary treatment options to choose from for the management of many chronic diseases. Shared decision making represents a promising approach to improve the quality of the decision making process needed for dietary choices that are informed by the best evidence and value-based. However, there are no studies reporting on theory-based approaches that foster the implementation of shared decision making in health professions allied to medicine. The objectives of this study are to explore the integration of shared decision making within real nutritional consultations, and to design questionnaires to assess dieticians' intention to adopt two specific behaviors related to shared decision making using the Theory of Planned Behavior. Methods Forty dieticians will audiotape one clinical encounter to explore the presence of shared decision making within the consultation. They will also participate to one of five to six focus groups that aim to identify the salient beliefs underlying the determinants of their intention to present evidence-based dietary treatment options to their patients, and clarify the values related to dietary choices that are important to their patients. These salient beliefs will be used to elaborate the items of two questionnaires. The internal consistency of theoretical constructs and the temporal stability of their measurement will be checked using the test-retest method by asking 35 dieticians to complete the questionnaire twice within a two-week interval. Discussion The proposed research project will be the first study to: provide preliminary data about the adoption of shared decision making by dieticians and theirs patients; elicit dieticians' salient beliefs regarding the intention to adopt shared decision making behaviors, report on the development of a specific questionnaire; explore dieticians' views on the implementation of shared decision making; and compare their views regarding the implementation of

  17. 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.

  18. Influence of MRI field strength on clinical decision making in knee cartilage injury - A case study.

    PubMed

    Cashman, Glenn; Attariwala, Raj

    2014-12-01

    To increase clinicians' awareness of the differences in image resolution and potential diagnostic accuracy between small and large-field MR Scanners. To present an example of a clinical decision making challenge in how to proceed when knee MRI and clinical findings don't agree. A 38 year old female mountain biker presented with knee pain and clinical features strongly suggestive of a torn meniscus or loose bodies. An initial MRI using a small field strength (0.18T) scanner was reported as normal. Her clinical presentation was suspicious enough that a repeat MRI on a high-field (1.5T) scanner was ordered. The second MRI included high resolution 3D volumetric imaging which revealed cartilage damage and loose bodies. The patient was treated with arthroscopic surgery which confirmed the presence of meniscal and chondral injury and resulted in notable improvement in the patient's symptoms. Clinicians should consider scanner quality and diagnostic accuracy before discounting strongly suggestive clinical history and examination findings when MRIs are reported as normal.

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

    PubMed Central

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

    2016-01-01

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

  20. Decision Making and Cancer

    PubMed Central

    Reyna, Valerie F.; Nelson, Wendy L.; Han, Paul K.; Pignone, Michael P.

    2014-01-01

    We review decision-making along the cancer continuum in the contemporary context of informed and shared decision making, in which patients are encouraged to take a more active role in their health care. We discuss challenges to achieving informed and shared decision making, including cognitive limitations and emotional factors, but argue that understanding the mechanisms of decision making offers hope for improving decision support. Theoretical approaches to decision making that explain cognition, emotion, and their interaction are described, including classical psychophysical approaches, dual-process approaches that focus on conflicts between emotion versus cognition (or reason), and modern integrative approaches such as fuzzy-trace theory. In contrast to the earlier emphasis on rote use of numerical detail, modern approaches emphasize understanding the bottom-line gist of options (which encompasses emotion and other influences on meaning) and retrieving relevant social and moral values to apply to those gist representations. Finally, research on interventions to support better decision making in clinical settings is reviewed, drawing out implications for future research on decision making and cancer. PMID:25730718

  1. A structured process to develop scenarios for use in evaluation of an evidence-based approach in clinical decision making.

    PubMed

    Manns, Patricia J; Darrah, Johanna

    2012-01-01

    Scenarios are used as the basis from which to evaluate the use of the components of evidence-based practice in decision making, yet there are few examples of a standardized process of scenario writing. The aim of this paper is to describe a step-by-step scenario writing method used in the context of the authors' curriculum research study. Scenario writing teams included one physical therapy clinician and one academic staff member. There were four steps in the scenario development process: (1) identify prevalent condition and brainstorm interventions; (2) literature search; (3) develop scenario framework; and (4) write scenario. Scenarios focused only on interventions, not diagnostic or prognostic problems. The process led to two types of scenarios - ones that provided an intervention with strong research evidence and others where the intervention had weak evidence to support its use. The end product of the process was a scenario that incorporates aspects of evidence-based decision making and can be used as the basis for evaluation. The use of scenarios has been very helpful to capture therapists' reasoning processes. The scenario development process was applied in an education context as part of a final evaluation of graduating clinical physical therapy students.

  2. A structured process to develop scenarios for use in evaluation of an evidence-based approach in clinical decision making

    PubMed Central

    Manns, Patricia J; Darrah, Johanna

    2012-01-01

    Background and purpose Scenarios are used as the basis from which to evaluate the use of the components of evidence-based practice in decision making, yet there are few examples of a standardized process of scenario writing. The aim of this paper is to describe a step-by-step scenario writing method used in the context of the authors’ curriculum research study. Methods Scenario writing teams included one physical therapy clinician and one academic staff member. There were four steps in the scenario development process: (1) identify prevalent condition and brainstorm interventions; (2) literature search; (3) develop scenario framework; and (4) write scenario. Results Scenarios focused only on interventions, not diagnostic or prognostic problems. The process led to two types of scenarios – ones that provided an intervention with strong research evidence and others where the intervention had weak evidence to support its use. The end product of the process was a scenario that incorporates aspects of evidence-based decision making and can be used as the basis for evaluation. Conclusion The use of scenarios has been very helpful to capture therapists’ reasoning processes. The scenario development process was applied in an education context as part of a final evaluation of graduating clinical physical therapy students. PMID:23762009

  3. Choice Set Size and Decision-Making: The Case of Medicare Part D Prescription Drug Plans

    PubMed Central

    Bundorf, M. Kate; Szrek, Helena

    2013-01-01

    Background The impact of choice on consumer decision-making is controversial in U.S. health policy. Objective Our objective was to determine how choice set size influences decision-making among Medicare beneficiaries choosing prescription drug plans. Methods We randomly assigned members of an internet-enabled panel age 65 and over to sets of prescription drug plans of varying sizes (2, 5, 10, and 16) and asked them to choose a plan. Respondents answered questions about the plan they chose, the choice set, and the decision process. We used ordered probit models to estimate the effect of choice set size on the study outcomes. Results Both the benefits of choice, measured by whether the chosen plan is close to the ideal plan, and the costs, measured by whether the respondent found decision-making difficult, increased with choice set size. Choice set size was not associated with the probability of enrolling in any plan. Conclusions Medicare beneficiaries face a tension between not wanting to choose from too many options and feeling happier with an outcome when they have more alternatives. Interventions that reduce cognitive costs when choice sets are large may make this program more attractive to beneficiaries. PMID:20228281

  4. Choice set size and decision making: the case of Medicare Part D prescription drug plans.

    PubMed

    Bundorf, M Kate; Szrek, Helena

    2010-01-01

    The impact of choice on consumer decision making is controversial in US health policy. The authors' objective was to determine how choice set size influences decision making among Medicare beneficiaries choosing prescription drug plans. The authors randomly assigned members of an Internet-enabled panel age 65 and older to sets of prescription drug plans of varying sizes (2, 5, 10, and 16) and asked them to choose a plan. Respondents answered questions about the plan they chose, the choice set, and the decision process. The authors used ordered probit models to estimate the effect of choice set size on the study outcomes. Both the benefits of choice, measured by whether the chosen plan is close to the ideal plan, and the costs, measured by whether the respondent found decision making difficult, increased with choice set size. Choice set size was not associated with the probability of enrolling in any plan. Medicare beneficiaries face a tension between not wanting to choose from too many options and feeling happier with an outcome when they have more alternatives. Interventions that reduce cognitive costs when choice sets are large may make this program more attractive to beneficiaries.

  5. 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

    2017-05-30

    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

  6. Esophageal perforation: diagnostic work-up and clinical decision-making in the first 24 hours

    PubMed Central

    2011-01-01

    Esophageal perforation is a rare and potentially life-threatening condition. Early clinical suspicion and imaging is important for case management to achieve a good outcome. However, recent studies continue to report high morbidity and mortality greater than 20% from esophageal perforation. At least half of the perforations are iatrogenic, mostly related to endoscopic instrumentation used in the upper gastrointestinal tract, while about a third are spontaneous perforations. Surgical treatment remains an important option for many patients, but a non-operative approach, with or without use of an endoscopic stent or placement of internal or external drains, should be considered when the clinical situation allows for a less invasive approach. The rarity of this emergency makes it difficult for a physician to obtain extensive individual clinical experience; it is also challenging to obtain firm scientific evidence that informs patient management and clinical decision-making. Improved attention to non-specific symptoms and signs and early diagnosis based on imaging may translate into better outcomes for this group of patients, many of whom are elderly with significant comorbidity. PMID:22035338

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

    PubMed

    Risør, Torsten

    2016-11-17

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

  8. A Windows-based tool for the study of clinical decision-making.

    PubMed

    Mackel, J V; Farris, H; Mittman, B S; Wilkes, M; Kanouse, D E

    1995-01-01

    Studies of health-provider decision-making, and of their practice patterns, play a central role in efforts to improve the quality and effectiveness of care and in decreasing costs of healthcare delivery systems. Researchers from a variety of disciplines have studied a broad range of clinical conditions, using a number of methodological approaches and measurement tools, including self-report, written clinical vignettes, simulated clinical encounters using actors as patients and analysis of medical records and administrative data. Although these provide information about the outcomes of clinical decisions, they provide little or no information about the process of the decision. Most clinicians agree that the decision process is as important as the outcome, and indeed it is not unusual to have an exemplary process but a poor outcome. Process information is therefore a crucial dimension of care evaluation. In this paper, we describe a new software product that was originally used to measure diagnostic reasoning in the basic medical science of immunology; subsequently adapted to measure key steps in the clinical decision-making process. This Windows-based software is user-friendly, inexpensive, and requires only commonly available hardware for its operation. It is very flexible, permitting the creation of unlimited numbers and types of clinical scenarios, with diagnostic and/or management approaches. Being clinically "real-world," the scenarios are familiar to the user, who is therefore likely to respond in a "real-world" fashion, with the consequent improved accuracy of data. In addition, a wide range of users may be accommodated. The clinical activities of physicians, nurses, pharmacists, and any other clinical providers may be measured and analyzed by the system. Non-clinical providers, such as managers and administrators, could also be assessed. The system has three major modes. In the Authoring Mode, the author creates a menu, which is common to a number of linked

  9. Nottingham Prognostic Index Plus (NPI+): a modern clinical decision making tool in breast cancer

    PubMed Central

    Rakha, E A; Soria, D; Green, A R; Lemetre, C; Powe, D G; Nolan, C C; Garibaldi, J M; Ball, G; Ellis, I O

    2014-01-01

    Background: Current management of breast cancer (BC) relies on risk stratification based on well-defined clinicopathologic factors. Global gene expression profiling studies have demonstrated that BC comprises distinct molecular classes with clinical relevance. In this study, we hypothesised that molecular features of BC are a key driver of tumour behaviour and when coupled with a novel and bespoke application of established clinicopathologic prognostic variables can predict both clinical outcome and relevant therapeutic options more accurately than existing methods. Methods: In the current study, a comprehensive panel of biomarkers with relevance to BC was applied to a large and well-characterised series of BC, using immunohistochemistry and different multivariate clustering techniques, to identify the key molecular classes. Subsequently, each class was further stratified using a set of well-defined prognostic clinicopathologic variables. These variables were combined in formulae to prognostically stratify different molecular classes, collectively known as the Nottingham Prognostic Index Plus (NPI+). The NPI+ was then used to predict outcome in the different molecular classes. Results: Seven core molecular classes were identified using a selective panel of 10 biomarkers. Incorporation of clinicopathologic variables in a second-stage analysis resulted in identification of distinct prognostic groups within each molecular class (NPI+). Outcome analysis showed that using the bespoke NPI formulae for each biological BC class provides improved patient outcome stratification superior to the traditional NPI. Conclusion: This study provides proof-of-principle evidence for the use of NPI+ in supporting improved individualised clinical decision making. PMID:24619074

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

    PubMed

    Chessare, J B

    1998-04-01

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

  11. Informational resources utilized in clinical decision making: common practices in dentistry.

    PubMed

    Straub-Morarend, Cheryl L; Marshall, Teresa A; Holmes, David C; Finkelstein, Michael W

    2011-04-01

    This study investigated current trends of Iowa dental practitioners with regard to acquisition and utilization of scientific information resources to support decision making in the clinical practice of dentistry. A survey questionnaire regarding the utilization of various sources of information to support clinical decisions was mailed in September 2009 to all dentists licensed and practicing in the state of Iowa. Dentists appointed full-time within the University of Iowa College of Dentistry were excluded from this study. Continuing education courses were the most frequently utilized and preferred information source by respondents, followed by print journals and consultation with other health care professionals. Practice patterns according to decade of dental school graduation as well as scope of practice were noted. The results of this study demonstrate that dental practitioners utilize a variety of evidence-based and non-evidence-based information resources to support decisions in clinical practice. The habits of newer graduates vary somewhat from those of earlier graduates; the habits of specialists vary from those of general practitioners.

  12. Thomas: building Bayesian statistical expert systems to aid in clinical decision making.

    PubMed

    Lehmann, H P; Shortliffe, E H

    1991-08-01

    Knowledge-based system for classical statistical analysis must separate the task of analyzing data from that of using the results of the analysis. In contrast, a Bayesian framework for building biostatistical expert system allows for the integration of the data-analytic and decision-making tasks. The architecture of such a framework entails enabling the system (1) to make its recommendations on decision-analytic grounds; (2) to construct statistical models dynamically; (3) to update a statistical model based on the user's prior beliefs and on data from, the methodological concerns evinced by, the study. This architecture permits the knowledge engineer to represent a variety of types of statistical and domain knowledge. Construction of such systems requires that the knowledge engineer reinterpret traditional statistical concerns, such as by replacing the notion of statistical significance with that of a pragmatic clinical threshold. The clinical user of such a system can interact with the system at a semantic level appropriate to her fund of methodological knowledge, rather than at the level of statistical details. We demonstrate these issues with a prototype system called THOMAS which helps a physician decision maker interpret the results of a published randomized clinical trial.

  13. Paying for treatments? Influences on negotiating clinical need and decision-making for dental implant treatment

    PubMed Central

    Exley, Catherine E; Rousseau, Nikki S; Steele, Jimmy; Finch, Tracy; Field, James; Donaldson, Cam; Thomason, J Mark; May, Carl R; Ellis, Janice S

    2009-01-01

    Background The aim of this study is to examine how clinicians and patients negotiate clinical need and treatment decisions within a context of finite resources. Dental implant treatment is an effective treatment for missing teeth, but is only available via the NHS in some specific clinical circumstances. The majority of people who receive this treatment therefore pay privately, often at substantial cost to themselves. People are used to paying towards dental treatment costs. However, dental implant treatment is much more expensive than existing treatments – such as removable dentures. We know very little about how dentists make decisions about whether to offer such treatments, or what patients consider when deciding whether or not to pay for them. Methods/Design Mixed methods will be employed to provide insight and understanding into how clinical need is determined, and what influences people's decision making processes when deciding whether or not to pursue a dental implant treatment. Phase 1 will use a structured scoping questionnaire with all the General dental practitioners (GDPs) in three Primary Care Trust areas (n = 300) to provide base-line data about existing practice in relation to dental implant treatment, and to provide data to develop a systematic sampling procedure for Phase 2. Phases 2 (GDPs) and 3 (patients) use qualitative focused one to one interviews with a sample of these practitioners (up to 30) and their patients (up to 60) to examine their views and experiences of decision making in relation to dental implant treatment. Purposive sampling for phases 2 and 3 will be carried out to ensure participants represent a range of socio-economic circumstances, and choices made. Discussion Most dental implant treatment is conducted in primary care. Very little information was available prior to this study about the quantity and type of treatment carried out privately. It became apparent during phase 2 that ISOD treatment was an unusual treatment in

  14. 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.

  15. Facilitating clinical decision-making about the use of virtual reality within paediatric motor rehabilitation: application of a classification framework.

    PubMed

    Levac, Danielle E; Galvin, Jane

    2011-01-01

    Multiple virtual reality (VR) systems are used to improve motor function in children and youth with neurological impairments. Galvin and Levac developed a classification framework to facilitate clinical decision-making about VR system use. This paper applies the classification framework to identify its strengths and limitations. The classification framework is applied to three case studies where therapists may consider using VR with children involved in paediatric rehabilitation programmes. The classification framework identified VR systems that met each child's individual needs. The relevance of each category to clinical decision-making varied depending on each child's goals. Categories requiring further development and suggestions for additional categories are discussed. The classification framework facilitates child-centred decision-making about the use of VR as a therapeutic intervention. It has shown initial utility but requires further validation with clinicians working in a variety of clinical settings and with a range of client populations.

  16. THOMAS: Building Bayesian Statistical Expert Systems to Aid in Clinical Decision Making

    PubMed Central

    Lehmann, Harold P.; Shortliffe, Edward H.

    1990-01-01

    Previous knowledge-based systems for statistical analysis separate the numeric knowledge needed for data analysis from the heuristic knowledge employed in using the results of the analysis. In contrast, a Bayesian framework for building biostatistical expert systems allows for the integration of the data-analytic and decision-making tasks. The architecture of such a framework entails enabling the system (1) to make its recommendations on decision-analytic grounds; (2) to update a statistical model based on the user's prior beliefs and on data from, and methodological concerns evinced by, the study; (3) to construct statistical models dynamically. This architecture permits the knowledge engineer to represent a variety of types of statistical and domain knowledge, such as methodological knowledge. Construction of such systems requires that the knowledge engineer reinterpret traditional statistical concerns, such as by replacing the notion of statistical significance with that of a pragmatic clinical threshold. The user of such a system can interact with the system at the level of general methodological concerns, rather than at the level of statistical details. We demonstrate these issues with a prototype system called THOMAS which helps a physician decision maker to interpret the results of a published randomized clinical trial.

  17. Virtual clinics in glaucoma care: face-to-face versus remote decision-making.

    PubMed

    Clarke, Jonathan; Puertas, Renata; Kotecha, Aachal; Foster, Paul J; Barton, Keith

    2017-07-01

    To examine the agreement in clinical decisions of glaucoma status made in a virtual glaucoma clinic with those made during a face-to-face consultation. A trained nurse and technicians entered data prospectively for 204 patients into a proforma. A subsequent face-to-face clinical assessment was completed by either a glaucoma consultant or fellow. Proformas were reviewed remotely by one of two additional glaucoma consultants, and 12 months later, by the clinicians who had undertaken the original clinical examination. The interobserver and intraobserver decision-making agreements of virtual assessment versus standard care were calculated. We identified adverse disagreement between face-to-face and virtual review in 7/204 (3.4%, 95% CI 0.9% to 5.9%) patients, where virtual review failed to predict a need to accelerated follow-up identified in face-to-face review. Misclassification events were rare, occurring in 1.9% (95% CI 0.3% to 3.8%) of assessments. Interobserver κ (95% CI) showed only fair agreement (0.24 (0.04 to 0.43)); this improved to moderate agreement when only consultant decisions were compared against each other (κ=0.41 (0.16 to 0.65)). The intraobserver agreement κ (95% CI) for the consultant was 0.274 (0.073 to 0.476), and that for the fellow was 0.264 (0.031 to 0.497). The low rate of adverse misclassification, combined with the slowly progressive nature of most glaucoma, and the fact that patients will all be regularly reassessed, suggests that virtual clinics offer a safe, logistically viable option for selected patients with glaucoma. 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/.

  18. [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.

  19. 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.

  20. Survey of critical thinking and clinical decision making in nursing student of Kerman University.

    PubMed

    Noohi, Esmat; Karimi-Noghondar, Maryam; Haghdoost, Aliakbar

    2012-09-01

    The ability to think critically is an essential element in nursing education and more specifically in nurses' clinical decision making (CDM). Critical thinking (CT) and CDM ability as well as their relationship were examined among nursing students of Kerman University. STUDY WAS DESIGNED IN FOUR TOWNS: Kerman, Bam, Jiroft, and Zarand, settled in Kerman province. This research was a cross-sectional descriptive correlation study. 300 nursing students with different level of education were asked to fill two questionnaires including: (1) California Critical Thinking Skills Test (CCTST) and (2) Lauri and Salantera (2002) CDM instrument. Data were analyzed with SPSS12 and descriptive and inferential statistics. Nursing students yielded a low score (mean = 5/40 from 20) of CT and a mild score (mean = 12.8 from 20) of CDM. We found positively correlation between male and CT and CDM score with mean score of the nursing student. Also CDM score in male was more than female but not significant, and Jirofts CDM nursing student was significantly better than other city. Although students that answers evaluation question in CCTST better can gave better CDM score but there isn't relationship between CT and CDM of nursing student. The finding showed that mean score of nursing student CT was low. Reason can be either due to the defects of nursing education program, teaching, and learning strategies.

  1. Supporting clinical decision making during deep brain stimulation surgery by means of a stochastic dynamical model

    NASA Astrophysics Data System (ADS)

    Karamintziou, Sofia D.; Tsirogiannis, George L.; Stathis, Pantelis G.; Tagaris, George A.; Boviatsis, Efstathios J.; Sakas, Damianos E.; Nikita, Konstantina S.

    2014-10-01

    Objective. During deep brain stimulation (DBS) surgery for the treatment of advanced Parkinson's disease (PD), microelectrode recording (MER) in conjunction with functional stimulation techniques are commonly applied for accurate electrode implantation. However, the development of automatic methods for clinical decision making has to date been characterized by the absence of a robust single-biomarker approach. Moreover, it has only been restricted to the framework of MER without encompassing intraoperative macrostimulation. Here, we propose an integrated series of novel single-biomarker approaches applicable to the entire electrophysiological procedure by means of a stochastic dynamical model. Approach. The methods are applied to MER data pertinent to ten DBS procedures. Considering the presence of measurement noise, we initially employ a multivariate phase synchronization index for automatic delineation of the functional boundaries of the subthalamic nucleus (STN) and determination of the acceptable MER trajectories. By introducing the index into a nonlinear stochastic model, appropriately fitted to pre-selected MERs, we simulate the neuronal response to periodic stimuli (130 Hz), and examine the Lyapunov exponent as an indirect indicator of the clinical effectiveness yielded by stimulation at the corresponding sites. Main results. Compared with the gold-standard dataset of annotations made intraoperatively by clinical experts, the STN detection methodology demonstrates a false negative rate of 4.8% and a false positive rate of 0%, across all trajectories. Site eligibility for implantation of the DBS electrode, as implicitly determined through the Lyapunov exponent of the proposed stochastic model, displays a sensitivity of 71.43%. Significance. The suggested comprehensive method exhibits remarkable performance in automatically determining both the acceptable MER trajectories and the optimal stimulation sites, thereby having the potential to accelerate precise

  2. Clinical Decision-Making Following Disasters: Efficient Identification of PTSD Risk in Adolescents.

    PubMed

    Danielson, Carla Kmett; Cohen, Joseph R; Adams, Zachary W; Youngstrom, Eric A; Soltis, Kathryn; Amstadter, Ananda B; Ruggiero, Kenneth J

    2017-01-01

    The present study aimed to utilize a Receiver Operating Characteristic (ROC) approach in order to improve clinical decision-making for adolescents at risk for the development of psychopathology in the aftermath of a natural disaster. Specifically we assessed theoretically-driven individual, interpersonal, and event-related vulnerability factors to determine which indices were most accurate in forecasting PTSD. Furthermore, we aimed to translate these etiological findings by identifying clinical cut-off recommendations for relevant vulnerability factors. Our study consisted of structured phone-based clinical interviews with 2000 adolescent-parent dyads living within a 5-mile radius of tornados that devastated Joplin, MO, and northern Alabama in Spring 2011. Demographics, tornado incident characteristics, prior trauma, mental health, and family support and conflict were assessed. A subset of youth completed two behavioral assessment tasks online to assess distress tolerance and risk-taking behavior. ROC analyses indicated four variables that significantly improved PTSD diagnostic efficiency: Lifetime depression (AUC = .90), trauma history (AUC = .76), social support (AUC = .70), and family conflict (AUC = .72). Youth were 2-3 times more likely to have PTSD if they had elevated scores on any of these variables. Of note, event-related characteristics (e.g., property damage) were not related to PTSD diagnostic status. The present study adds to the literature by making specific recommendations for empirically-based, efficient disaster-related PTSD assessment for adolescents following a natural disaster. Implications for practice and future trauma-related developmental psychopathology research are discussed.

  3. Referring periodontal patients: clinical decision making by dental and dental hygiene students.

    PubMed

    Williams, Karen B; Burgardt, Grayson J; Rapley, John W; Bray, Kimberly K; Cobb, Charles M

    2014-03-01

    Referral of periodontal patients requires development of a complex set of decision making skills. This study was conducted to determine criteria used by dental and dental hygiene students regarding the referral of periodontal patients for specialty care. Using mixed methods, a thirteen-item survey was developed to elicit the students' perceptions of their knowledge, confidence regarding managing patients, and clinical reasoning related to periodontal patients. The instrument was administered during the summer prior to (T1) and at the end of the students' final year (T2) of training. Seventy-nine dental students (81 percent of total class) and thirty dental hygiene students (83 percent of total class) completed T1. At T2, forty-two dental (44 percent of total class) and twenty-six dental hygiene students (87 percent of total class) completed the questionnaire. While 90 percent of dental and 96 percent of dental hygiene respondents reported a willingness to refer patients with active disease to specialists, only 40 percent of dental and 36 percent of dental hygiene respondents reported confidence in diagnosing, treating, and appropriately referring such patients. The students' ability to recognize critical disease and risk factors influencing referral was good; however, clinical application of that knowledge indicated a gap between knowledge and applied reasoning. The students' attitudes about the importance of periodontal disease and their perceived competence to identify critical disease risk factors were not significantly related (p>0.05) to correct clinical decisions in the case scenarios. The study concludes that dental and dental hygiene curricula should emphasize both the acquisition and application of knowledge regarding criteria for referral of periodontal patients.

  4. Healthcare decision-making in end stage renal disease-patient preferences and clinical correlates.

    PubMed

    Jayanti, Anuradha; Neuvonen, Markus; Wearden, Alison; Morris, Julie; Foden, Philip; Brenchley, Paul; Mitra, Sandip

    2015-11-14

    Medical decision-making is critical to patient survival and well-being. Patients with end stage renal disease (ESRD) are faced with incrementally complex decision-making throughout their treatment journey. The extent to which patients seek involvement in the decision-making process and factors which influence these in ESRD need to be understood. 535 ESRD patients were enrolled into the cross-sectional study arm and 30 patients who started dialysis were prospectively evaluated. Patients were enrolled into 3 groups- 'predialysis' (group A), 'in-centre' haemodialysis (HD) (group B) and self-care HD (93 % at home-group C) from across five tertiary UK renal centres. The Autonomy Preference Index (API) has been employed to study patient preferences for information-seeking (IS) and decision-making (DM). Demographic, psychosocial and neuropsychometric assessments are considered for analyses. 458 complete responses were available. API items have high internal consistency in the study population (Cronbach's alpha > 0.70). Overall and across individual study groups, the scores for information-seeking and decision-making are significantly different indicating that although patients had a strong preference to be well informed, they were more neutral in their preference to participate in DM (p < 0.05). In the age, education and study group adjusted multiple linear regression analysis, lower age, female gender, marital status; higher API IS scores and white ethnicity background were significant predictors of preference for decision-making. DM scores were subdivided into tertiles to identify variables associated with high (DM > 70: and low DM (≤30) scores. This shows association of higher DM scores with lower age, lower comorbidity index score, higher executive brain function, belonging in the self-caring cohort and being unemployed. In the prospectively studied cohort of predialysis patients, there was no change in decision-making preference scores after

  5. A role for the sick role: Patient preferences regarding information and participation in clinical decision-making

    PubMed Central

    Stiggelbout, A M; Kiebert, G M

    1997-01-01

    OBJECTIVE: To assess whether patient preferences regarding information and participation in decision-making about treatment options are related to patient characteristics and the context of the decision. Other studies have compared decision-making preferences in patients with cancer and healthy subjects, or in different contexts among patients in the same group. This study combined these designs. DESIGN: Questionnaire completed by the subjects. SETTING: Outpatient clinic of a university hospital. PARTICIPANTS: A consecutive sample of 55 patients with cancer treated at a radiotherapy clinic, 53 persons accompanying them, a consecutive sample of 53 patients visiting a surgical outpatient clinic for a nonmalignant condition and 36 persons accompanying them. MAIN MEASURES: Preferences regarding information and participation in decision-making in general and with respect to 4 vignettes that described different diseases of varying seriousness, varying treatment options and side effects. RESULTS: Older patients and men were more likely to let the physician make decisions regarding their treatment. Patients, as compared with nonpatients (their companions), were more likely to prefer a passive role regarding treatment decisions. No differences were seen between patients with cancer and patients with nonmalignant conditions. Also, no effect was observed in relation to the decision-making situations described in the vignettes. Of the patients who preferred more information, a substantial proportion still preferred a passive decision-making role. CONCLUSION: The lack of strong predictors of a preferred decision-making role implies that clinicians need to assess every patient individually to determine what role he or she prefers. The finding that the patients preferred a more passive role than their companions suggests that the "sick role" influences the preference regarding participation more strongly than the type of decision to be made or the presence of a life

  6. An Exploration of the Relationship between Clinical Decision-Making Ability and Educational Preparation among New Graduate Nurses

    ERIC Educational Resources Information Center

    Blount, Kamilah V.

    2013-01-01

    This study examined the impact of accelerated nursing direct entry master's programs on the development of clinical decision-making skills of new graduate nurses that completed the Performance Based Development System (PBDS) assessment during the study period of 2008-2012 at a healthcare organization. Healthcare today is practiced in a…

  7. An Exploration of the Relationship between Clinical Decision-Making Ability and Educational Preparation among New Graduate Nurses

    ERIC Educational Resources Information Center

    Blount, Kamilah V.

    2013-01-01

    This study examined the impact of accelerated nursing direct entry master's programs on the development of clinical decision-making skills of new graduate nurses that completed the Performance Based Development System (PBDS) assessment during the study period of 2008-2012 at a healthcare organization. Healthcare today is practiced in a…

  8. Vienna Summer School on Oncology: how to teach clinical decision making in a multidisciplinary environment.

    PubMed

    Lütgendorf-Caucig, Carola; Kaiser, Philipp A; Machacek, Alexandra; Waldstein, Cora; Pötter, Richard; Löffler-Stastka, Henriette

    2017-06-06

    Clinical decision making in oncology is based on both inter- and multidisciplinary approach. Hence teaching future doctors involved in oncology or general health practice is crucial. The aim of the Vienna Summer School on Oncology (VSSO) as an international, integrated, undergraduate oncology course is to teach medical students interdisciplinary team communication and application of treatment concepts/algorithms in a multidisciplinary setting. The teaching is based on an inter- and multidisciplinary faculty and a multimodal education approach to address different learning styles. The participants rated their satisfaction of the program voluntarily after finishing the course according to a grading scale from one (not good) to five (very good). The learning success was assessed by a compulsory pre-VSSO and post-VSSO single choice questionnaire. Program organisation was rated with a mean score of 4.47 out of 5.0 (SD 0.51), composition of the program and range of topics with a mean score of 4.68 (SD 0.58) and all teachers with a mean score of 4.36 (SD 0.40) points. Student evaluation at the beginning and end of the program indicated significant knowledge acquisition -i.e., general aspects of cancer: median 8.75 points (IQR 7.5-9.4) vs.10.0 points (IQR 9.4-10.0) p = 0.005; specific aspects of cancer: median 4.87 points (IQR 3.33-5.71) vs. 8.72 points (IQR 6.78-9.49) p ≤ 0.001, respectively. Even though the participants represent a selection of students with special interest in cancer, the results of the VSSO indicate the benefit of an inter- and multidisciplinary teaching approach within an oncology module.

  9. Real life clinic visits do not match the ideals of shared decision making.

    PubMed

    Lipstein, Ellen A; Dodds, Cassandra M; Britto, Maria T

    2014-07-01

    To use observation to understand how decisions about higher-risk treatments, such as biologics, are made in pediatric chronic conditions. Gastroenterology and rheumatology providers who prescribe biologics were recruited. Families were recruited when they had an outpatient appointment in which treatment with biologics was likely to be discussed. Consent/assent was obtained to video the visit. Audio of the visits in which a discussion of biologics took place were transcribed and analyzed. Our coding structure was based on prior research, shared decision making (SDM) concepts, and the initial recorded visits. Coded data were analyzed using content analysis and comparison with an existing model of SDM. We recorded 21 visits that included discussions of biologics. In most visits, providers initiated the decision-making discussion. Detailed information was typically given about the provider's preferred option with less information about other options. There was minimal elicitation of preferences, treatment goals, or prior knowledge. Few parents or patients spontaneously stated their preferences or concerns. An implicit or explicit treatment recommendation was given in nearly all visits, although rarely requested. In approximately one-third of the visits, the treatment decision was never made explicit, yet steps were taken to implement the provider's preferred treatment. We observed limited use of SDM, despite previous research indicating that parents wish to collaborate in decision making. To better achieve SDM in chronic conditions, providers and families need to strive for bidirectional sharing of information and an explicit family role in decision making. Copyright © 2014 Elsevier Inc. All rights reserved.

  10. Nonclinical influences, beyond diagnosis and severity, on clinical decision making in dermatology: understanding the gap between guidelines and practice.

    PubMed

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

    2010-10-01

    Clinical decision making in dermatology is a complex process and might be influenced by a wide range of nonclinical factors. The aim of this study was to explore the role of nonclinical influences, beyond diagnosis and severity, on clinical decision making in dermatology. Semi-structured qualitative interviews were conducted with 46 clinicians working in departments of dermatology of nine different hospitals in Wales. Interviews were audio-recorded and later transcribed and their contents analysed. Nonclinical factors influencing patient management decisions in dermatology that were identified related to patients, clinicians and practice characteristics. Patient-related factors included place of residence, socioeconomic circumstances, education and intelligence, ethnicity, age, treatment adherence, expectations from treatment, quality of life, concerns and worries, difficult patients, and family members or friends. Clinician-related factors included time constraints in clinic, clinicians' personal circumstances, relationship with colleagues, and relationship with pharmaceutical companies. Practice-related factors included working in private practice, cost of treatment to the National Health Service (NHS), prescribing bureaucracy, and availability of treatment service in the work place. There was a difference between the consultants' views and those of the other clinicians over the impact of pharmaceutical companies on clinicians' prescribing and the awareness of treatment costs to the NHS. Most of the factors identified could potentially influence the clinicians' decision-making process subconsciously. Some clinicians highlighted that these factors are untaught in the medical curriculum, and are usually ignored in clinical guidelines, and therefore represent a challenge to the practice of evidence-based medicine. This study has described one aspect of the reality of medical decision making beyond the conventional evidence-based guidelines approach. Proper

  11. The effect of multimedia replacing text in resident clinical decision-making assessment.

    PubMed

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

    2016-10-17

    Multimedia in assessing clinical decision-making skills (CDMS) has been poorly studied, particularly in comparison to traditional text-based assessments. The literature suggests multimedia is more difficult for trainees. We hypothesize that pediatric residents score lower in diagnostic skill when clinical vignettes use multimedia rather than text for patient findings. A standardized method was developed to write text-based questions from 60 high-resolution, quality multimedia; a series of expert panels selected 40 questions with both a multimedia and text-based counterpart, and two online tests were developed. Each test featured 40 identical questions with reciprocal and alternating modality (multimedia vs. text). Pediatric residents and rising 4th year medical students (MS-IV) at a single residency were randomized to complete either test stratified by postgraduate training year (PGY). A mixed between-within subjects ANOVA analyzed differences in score due to modality and PGY. Secondary analyses ascertained modality effect in dermatology and respiratory questions using Mann-Whitney U tests, and correlations on test performance to In-service Training Exam (ITE) scores using Spearman rank. Eighty-eight residents and rising interns completed the study. Overall multimedia scores were lower than text-based scores (p = 0.047, η p(2)  = 0.04), with highest disparity in rising interns (MS-IV); however, PGY had a greater effect on scores (p = 0.001, η p(2)  = 0.16). Respiratory questions were not significantly lower with multimedia (n = 9, median 0.71 vs. 0.86, p = 0.09) nor dermatology questions (n = 13, p = 0.41). ITEs correlated significantly with text-based scores (ρ = 0.23-0.25, p = 0.04-0.06) but not with multimedia scores. In physician trainees with less clinical experience, multimedia-based case vignettes are associated with significantly lower scores. These results help shed light on the role of multimedia versus text-based information in

  12. Patient participation in clinical decision-making in nursing: A comparative study of nurses' and patients' perceptions.

    PubMed

    Florin, Jan; Ehrenberg, Anna; Ehnfors, Margareta

    2006-12-01

    The aim of this study was to compare the degree of concordance between patients and Registered Nurses' perceptions of the patients' preferences for participation in clinical decision-making in nursing care. A further aim was to compare patients' experienced participation with their preferred participatory role. Patient participation in clinical decision-making is valuable and has an effect on quality of care. However, there is limited knowledge about patient preferences for participation and how nurses perceive their patients' preferences. A comparative design was adopted with a convenient sample of 80 nurse-patient dyads. A modified version of the Control Preference Scale was used in conjunction with a questionnaire developed to elicit the experienced participation of the patient. A majority of the Registered Nurses perceived that their patients preferred a higher degree of participation in decision-making than did the patients. Differences in patient preferences were found in relation to age and social status but not to gender. Patients often experienced having a different role than what was initially preferred, e.g. a more passive role concerning needs related to communication, breathing and pain and a more active role related to activity and emotions/roles. Registered Nurses are not always aware of their patients' perspective and tend to overestimate patients' willingness to assume an active role. Registered Nurses do not successfully involve patients in clinical decision-making in nursing care according to their own perceptions and not even to the patients' more moderate preferences of participation. A thorough assessment of the individual's preferences for participation in decision-making seems to be the most appropriate approach to ascertain patient's involvement to the preferred level of participation. The categorization of patients as preferring a passive role, collaborative role or active role is seen as valuable information for Registered Nurses to

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

    PubMed

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

    2017-01-01

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

  14. Disciplined decision making in an interdisciplinary environment: some implications for clinical applications of statistical process control.

    PubMed Central

    Hantula, D A

    1995-01-01

    This paper explores some of the implications the statistical process control (SPC) methodology described by Pfadt and Wheeler (1995) may have for analyzing more complex performances and contingencies in human services or health care environments at an organizational level. Service delivery usually occurs in an organizational system that is characterized by functional structures, high levels of professionalism, subunit optimization, and organizational suboptimization. By providing a standard set of criteria and decision rules, SPC may provide a common interface for data-based decision making, may bring decision making under the control of the contigencies that are established by these rules rather than the immediate contingencies of data fluctuation, and may attenuate escalation of failing treatments. SPC is culturally consistent with behavior analysis, sharing an emphasis on data-based decisions, measurement over time, and graphic analysis of data, as well as a systemic view of organizations. PMID:7592155

  15. Clinical decision making and preference assessment for individuals with intellectual and developmental disabilities.

    PubMed

    Virués-Ortega, Javier; Pritchard, Kristen; Grant, Robin L; North, Sebastian; Hurtado-Parrado, Camilo; Lee, May S H; Temple, Bev; Julio, Flávia; Yu, C T

    2014-03-01

    Individuals with intellectual or developmental disabilities are able to reliably express their likes and dislikes through direct preference assessment. Preferred items tend to function as rewards and can therefore be used to facilitate the acquisition of new skills and promote task engagement. A number of preference assessment methods are available and selecting the appropriate method is crucial to provide reliable and meaningful results. The authors conducted a systematic review of the preference assessment literature, and developed an evidence-informed, decision-making model to guide practitioners in the selection of preference assessment methods for a given assessment scenario. The proposed decision-making model could be a useful tool to increase the usability and uptake of preference assessment methodology in applied settings.

  16. Factors related to decision making and substance use in adolescent survivors of childhood cancer: a presenting clinical profile.

    PubMed

    Hollen, P J; Tyc, V L; Shannon, S V; Donnangelo, S F; Hobbie, W L; Hudson, M M; O'Laughlen, M C; Smolkin, M E; Petroni, G R

    2013-09-01

    Adolescent survivors of childhood cancer are more vulnerable to the consequences of health risk behaviors because of the late effects of their disease and its treatment. Decision making related to risk behaviors is important as they have reached an age during which initiation of substance use risk behavior is common. Factors associated with decision making and substance use behaviors (smoking, alcohol use, and illicit drug use) were identified among adolescent survivors of childhood cancer, the role of cognitive function was examined, and their rates of substance use behaviors were compared to a sample from the general population. A cohort of 243 adolescent survivors, ages 14-19 years, participated who were recruited from three cancer centers (St. Jude Children's Research Hospital, Hackensack University, and Long Beach Medical Center). A cross-sectional survey was used to assess cognitive and psychosocial factors for a presenting clinical profile to predict quality decision making and substance use behaviors. Validated measures using online data entry were obtained at the time of their annual visit for evaluation of late effects of treatment. Cancer and treatment factors were abstracted from the medical record. Eight factors (nine for substance use risk behavior) were examined in two regression models, quality decision making and substance use. In the model to predict poor-quality decision making for this cohort, gender and risk motivation (a surrogate for resiliency to social influence) were each significant predictors, with male gender and less resiliency each associated with poor decision making. Significant predictors of lifetime substance use were older presenting age, lower resiliency to social influence, poorer abstract ability (representing executive function impairment), history of current school problems, and negative substance use risk behavior modeling by household members and closest friend; CNS-associated late effects were only marginally associated

  17. Amatoxin poisoning treatment decision-making: pharmaco-therapeutic clinical strategy assessment using multidimensional multivariate statistic analysis.

    PubMed

    Poucheret, Patrick; Fons, Françoise; Doré, Jean Christophe; Michelot, Didier; Rapior, Sylvie

    2010-06-15

    Ninety percent of fatal higher fungus poisoning is due to amatoxin-containing mushroom species. In addition to absence of antidote, no chemotherapeutic consensus was reported. The aim of the present study is to perform a retrospective multidimensional multivariate statistic analysis of 2110 amatoxin poisoning clinical cases, in order to optimize therapeutic decision-making. Our results allowed to classify drugs as a function of their influence on one major parameter: patient survival. Active principles were classified as first intention, second intention, adjuvant or controversial pharmaco-therapeutic clinical intervention. We conclude that (1) retrospective multidimensional multivariate statistic analysis of complex clinical dataset might help future therapeutic decision-making and (2) drugs such as silybin, N-acetylcystein and putatively ceftazidime are clearly associated, in amatoxin poisoning context, with higher level of patient survival.

  18. Physiologic aspects of aging: impact on cancer management and decision making, part II.

    PubMed

    Sehl, Mary; Sawhney, Rishi; Naeim, Arash

    2005-01-01

    In this second article of our two-part review, we focus on age-associated physiologic changes involving the nervous, endocrine, hematologic, immune, and musculoskeletal systems, with close attention to the interconnected nature of these systems. There is a well-known connection between the neuroendocrine and immune systems via the hypothalamic-pituitary-adrenal axis and via interaction by means of cytokines, hormones, and neurotransmitters. These changes may lead to a loss of integration and resiliency with age, thus decreasing the ability of the elderly patient with cancer to adapt to stressful circumstances. Prominent changes include decline in memory and cognition, and increased susceptibility to peripheral neuropathy. Hematologic and immune changes like reduced bone marrow reserve and increased susceptibility to infections have far reaching implications for cancer care in the elderly. Gradual decline in hormone levels, and changes in muscle and body composition, can lead to functional decline and frailty. Use of the clinical interventions suggested in this article, along with an appreciation of the interplay of these age-related physiologic changes and their consequences, allows oncology professionals to customize therapy and minimize side effects in the geriatric oncology patient.

  19. Clinical decision making in spinal fusion for chronic low back pain. Results of a nationwide survey among spine surgeons.

    PubMed

    Willems, Paul; de Bie, Rob; Oner, Cumhur; Castelein, René; de Kleuver, Marinus

    2011-01-01

    Objectives To assess the use of prognostic patient factors and predictive tests in clinical decision making for spinal fusion in patients with chronic low back pain. Design and setting Nationwide survey among spine surgeons in the Netherlands. Participants Surgeon members of the Dutch Spine Society were questioned on their surgical treatment strategy for chronic low back pain. Primary and secondary outcome measures The surgeons' opinion on the use of prognostic patient factors and predictive tests for patient selection were addressed on Likert scales, and the degree of uniformity was assessed. In addition, the influence of surgeon-specific factors, such as clinical experience and training, on decision making was determined. Results The comments from 62 surgeons (70% response rate) were analysed. Forty-four surgeons (71%) had extensive clinical experience. There was a statistically significant lack of uniformity of opinion in seven of the 11 items on prognostic factors and eight of the 11 items on predictive tests, respectively. Imaging was valued much higher than predictive tests, psychological screening or patient preferences (all p<0.01). Apart from the use of discography and long multisegment fusions, differences in training or clinical experience did not appear to be of significant influence on treatment strategy. Conclusions The present survey showed a lack of consensus among spine surgeons on the appreciation and use of predictive tests. Prognostic patient factors were not consistently incorporated in their treatment strategy either. Clinical decision making for spinal fusion to treat chronic low back pain does not have a uniform evidence base in practice. Future research should focus on identifying subgroups of patients for whom spinal fusion is an effective treatment, as only a reliable prediction of surgical outcome, combined with the implementation of individual patient factors, may enable the instalment of consensus guidelines for surgical decision

  20. Clinical decision making in spinal fusion for chronic low back pain. Results of a nationwide survey among spine surgeons

    PubMed Central

    de Bie, Rob; Öner, Cumhur; Castelein, René; de Kleuver, Marinus

    2011-01-01

    Objectives To assess the use of prognostic patient factors and predictive tests in clinical decision making for spinal fusion in patients with chronic low back pain. Design and setting Nationwide survey among spine surgeons in the Netherlands. Participants Surgeon members of the Dutch Spine Society were questioned on their surgical treatment strategy for chronic low back pain. Primary and secondary outcome measures The surgeons' opinion on the use of prognostic patient factors and predictive tests for patient selection were addressed on Likert scales, and the degree of uniformity was assessed. In addition, the influence of surgeon-specific factors, such as clinical experience and training, on decision making was determined. Results The comments from 62 surgeons (70% response rate) were analysed. Forty-four surgeons (71%) had extensive clinical experience. There was a statistically significant lack of uniformity of opinion in seven of the 11 items on prognostic factors and eight of the 11 items on predictive tests, respectively. Imaging was valued much higher than predictive tests, psychological screening or patient preferences (all p<0.01). Apart from the use of discography and long multisegment fusions, differences in training or clinical experience did not appear to be of significant influence on treatment strategy. Conclusions The present survey showed a lack of consensus among spine surgeons on the appreciation and use of predictive tests. Prognostic patient factors were not consistently incorporated in their treatment strategy either. Clinical decision making for spinal fusion to treat chronic low back pain does not have a uniform evidence base in practice. Future research should focus on identifying subgroups of patients for whom spinal fusion is an effective treatment, as only a reliable prediction of surgical outcome, combined with the implementation of individual patient factors, may enable the instalment of consensus guidelines for surgical decision

  1. WHAT ARE ‘BEST INTERESTS’? A CRITICAL EVALUATION OF ‘BEST INTERESTS’ DECISION-MAKING IN CLINICAL PRACTICE

    PubMed Central

    Taylor, Helen J.

    2016-01-01

    Obtaining the patient's consent is usually a prerequisite of any clinical intervention. However, some cognitively impaired patients may not be able to give valid consent. Following years of consultation and legislative review, the Mental Capacity Act 2005 (MCA) provides a statutory framework of ‘best interests’ decision-making on behalf of incapacitated individuals. However, confusion over the meaning and application of the ‘best interests’ standard persists. This paper explores the variation in judicial interpretation of the standard and the complexities of best interests decision-making in clinical practice. Prevailing confusion and risk-aversive practices mean that the rights and interests of cognitively impaired individuals continue to be compromised, with evidence to suggest that ‘best interests’ may be conflated with the clinician's evaluation of ‘best medical interests’. PMID:26979251

  2. Nurses' Clinical Decision Making on Adopting a Wound Clinical Decision Support System.

    PubMed

    Khong, Peck Chui Betty; Hoi, Shu Yin; Holroyd, Eleanor; Wang, Wenru

    2015-07-01

    Healthcare information technology systems are considered the ideal tool to inculcate evidence-based nursing practices. The wound clinical decision support system was built locally to support nurses to manage pressure ulcer wounds in their daily practice. However, its adoption rate is not optimal. The study's objective was to discover the concepts that informed the RNs' decisions to adopt the wound clinical decision support system as an evidence-based technology in their nursing practice. This was an exploratory, descriptive, and qualitative design using face-to-face interviews, individual interviews, and active participatory observation. A purposive, theoretical sample of 14 RNs was recruited from one of the largest public tertiary hospitals in Singapore after obtaining ethics approval. After consenting, the nurses were interviewed and observed separately. Recruitment stopped when data saturation was reached. All transcribed interview data underwent a concurrent thematic analysis, whereas observational data were content analyzed independently and subsequently triangulated with the interview data. Eight emerging themes were identified, namely, use of the wound clinical decision support system, beliefs in the wound clinical decision support system, influences of the workplace culture, extent of the benefits, professional control over nursing practices, use of knowledge, gut feelings, and emotions (fear, doubt, and frustration). These themes represented the nurses' mental outlook as they made decisions on adopting the wound clinical decision support system in light of the complexities of their roles and workloads. This research has provided insight on the nurses' thoughts regarding their decision to interact with the computer environment in a Singapore context. It captured the nurses' complex thoughts when deciding whether to adopt or reject information technology as they practice in a clinical setting.

  3. Clinical Equipoise and Shared Decision-making in Pulmonary Nodule Management. A Survey of American Thoracic Society Clinicians.

    PubMed

    Iaccarino, Jonathan M; Simmons, James; Gould, Michael K; Slatore, Christopher G; Woloshin, Steven; Schwartz, Lisa M; Wiener, Renda Soylemez

    2017-06-01

    Guidelines for pulmonary nodule evaluation suggest a variety of strategies, reflecting the lack of high-quality evidence demonstrating the superiority of any one approach. It is unclear whether clinicians agree that multiple management options are appropriate at different levels of risk and whether this impacts their decision-making approaches with patients. To assess clinicians' perceptions of the appropriateness of various diagnostic strategies, approach to decision-making, and perceived clinical equipoise in pulmonary nodule evaluation. We developed and administered a web-based survey in March and April, 2014 to clinician members of the American Thoracic Society. The primary outcome was perceived appropriateness of pulmonary nodule evaluation strategies in three clinical vignettes with different malignancy risk. We compared responses to guideline recommendations and analyzed clinician characteristics associated with a reported shared decision-making approach. We also assessed clinicians' likelihood to enroll patients in hypothetical randomized trials comparing nodule evaluation strategies. Of 5,872 American Thoracic Society members e-mailed, 1,444 opened the e-mail and 428 eligible clinicians participated in the survey (response rate, 30.0% among those who opened the invitation; 7% overall). The mean number of options considered appropriate increased with pretest probability of cancer, ranging from 1.8 (SD, 1.2) for the low-risk case to 3.5 (1.1) for the high-risk case (P < 0.0001). As recommended by guidelines, the proportion that deemed surgical resection as an appropriate option also increased with cancer risk (P < 0.0001). One-half of clinicians (50.4%) reported engaging in shared decision-making with patients for pulmonary nodule management; this was more commonly reported by clinicians with more years of experience (P = 0.01) and those who reported greater comfort in managing pulmonary nodules (P = 0.005). Although one-half (49.9%) deemed

  4. Using the theory of planned behaviour to predict nurses' intention to integrate research evidence into clinical decision-making.

    PubMed

    Côté, Françoise; Gagnon, Johanne; Houme, Philippe Kouffé; Abdeljelil, Anis Ben; Gagnon, Marie-Pierre

    2012-10-01

    Using an extended theory of planned behaviour, this article is a report of a study to identify the factors that influence nurses' intention to integrate research evidence into their clinical decision-making. Health professionals are increasingly asked to adopt evidence-based practice. The integration of research evidence in nurses' clinical decision-making would have an important impact on the quality of care provided for patients. Despite evidence supporting this practice and the availability of high quality research in the field of nursing, the gap between research and practice is still present. A predictive correlational study. A total of 336 nurses working in a university hospital participated in this research. Data were collected in February and March 2008 by means of a questionnaire based on an extension of the theory of planned behaviour. Descriptive statistics of the model variables, Pearson correlations between all the variables and multiple linear regression analysis were performed. Nurses' intention to integrate research findings into clinical decision-making can be predicted by moral norm, normative beliefs, perceived behavioural control and past behaviour. The moral norm is the most important predictor. Overall, the final model explains 70% of the variance in nurses' intention. The present study supports the use of an extended psychosocial theory for identifying the determinants of nurses' intention to integrate research evidence into their clinical decision-making. Interventions that focus on increasing nurses' perceptions that using research is their responsibility for ensuring good patient care and providing a supportive environment could promote an evidence-based nursing practice. © 2012 Blackwell Publishing Ltd.

  5. 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.

  6. Racial, gender, and socioeconomic status bias in senior medical student clinical decision-making: a national survey.

    PubMed

    Williams, Robert L; Romney, Crystal; Kano, Miria; Wright, Randy; Skipper, Betty; Getrich, Christina M; Sussman, Andrew L; Zyzanski, Stephen J

    2015-06-01

    Research suggests stereotyping by clinicians as one contributor to racial and gender-based health disparities. It is necessary to understand the origins of such biases before interventions can be developed to eliminate them. As a first step toward this understanding, we tested for the presence of bias in senior medical students. The purpose of the study was to determine whether bias based on race, gender, or socioeconomic status influenced clinical decision-making among medical students. We surveyed seniors at 84 medical schools, who were required to choose between two clinically equivalent management options for a set of cardiac patient vignettes. We examined variations in student recommendations based on patient race, gender, and socioeconomic status. The study included senior medical students. We investigated the percentage of students selecting cardiac procedural options for vignette patients, analyzed by patient race, gender, and socioeconomic status. Among 4,603 returned surveys, we found no evidence in the overall sample supporting racial or gender bias in student clinical decision-making. Students were slightly more likely to recommend cardiac procedural options for black (43.9 %) vs. white (42 %, p = .03) patients; there was no difference by patient gender. Patient socioeconomic status was the strongest predictor of student recommendations, with patients described as having the highest socioeconomic status most likely to receive procedural care recommendations (50.3 % vs. 43.2 % for those in the lowest socioeconomic status group, p < .001). Analysis by subgroup, however, showed significant regional geographic variation in the influence of patient race and gender on decision-making. Multilevel analysis showed that white female patients were least likely to receive procedural recommendations. In the sample as a whole, we found no evidence of racial or gender bias in student clinical decision-making. However, we did find evidence of bias with regard to the

  7. Shared Surgical Decision-Making and Youth Resilience: Correlates of Satisfaction with Clinical Outcomes

    PubMed Central

    Kapp-Simon, Kathleen A; Edwards, Todd; Ruta, Caroline; Bellucci, Claudia Crilly; Aspirnall, Cassandra L.; Strauss, Ronald P; Topolski, Tari D.; Rumsey, Nichola J; Patrick, Donald L

    2015-01-01

    The aim of this study was to identify factors associated with youth satisfaction with surgical procedures performed to address oral cleft or craniofacial conditions (CFC). It was hypothesized that youth mental health, participation in decision-making, perceived consequences of living with a CFC, and coping strategies would be associated with satisfaction with past surgeries. Two hundred and three youth between the ages of 11 and 18 (Mean age = 14.5. SD = 2.0; 61% male; 78% oral cleft) completed a series of questionnaires measuring depression, self-esteem, participation in decision-making, condition severity, negative and positive consequences of having a CFC, coping, and satisfaction with past surgeries. Multiple Regression Analysis using boot-strapping techniques found that youth participation in decision making, youth perception of positive consequences of having a CFC, and coping accounted for 32% of the variance in satisfaction with past surgeries (p < .001). Youth age, sex, and assessment of condition severity were not significantly associated with satisfaction with surgical outcome. Depression, self-esteem, and negative consequences of having a CFC were not associated with satisfaction with past surgeries. Youth should be actively involved in the decision for craniofacial surgery. Youth who were more satisfied with their surgical outcomes also viewed themselves as having gained from the experience of living with a CFC. They felt that having a CFC made them stronger people and they believed that they were more accepting of others and more in touch with others’ feelings because of what they had been through. PMID:26114527

  8. Shared Surgical Decision Making and Youth Resilience Correlates of Satisfaction With Clinical Outcomes.

    PubMed

    Kapp-Simon, Kathleen A; Edwards, Todd; Ruta, Caroline; Bellucci, Claudia Crilly; Aspirnall, Cassandra L; Strauss, Ronald P; Topolski, Tari D; Rumsey, Nichola J; Patrick, Donald L

    2015-07-01

    The aim of this study was to identify factors associated with youth satisfaction with surgical procedures performed to address oral cleft or craniofacial conditions (CFCs). It was hypothesized that youth mental health, participation in decision making, perceived consequences of living with a CFC, and coping strategies would be associated with satisfaction with past surgeries. A total of 203 youth between the ages of 11 and 18 years (mean age = 14.5, standard deviation = 2.0, 61% male participants, 78% oral cleft) completed a series of questionnaires measuring depression, self-esteem, participation in decision making, condition severity, negative and positive consequences of having a CFC, coping, and satisfaction with past surgeries. Multiple regression analysis using boot-strapping techniques found that youth participation in decision making, youth perception of positive consequences of having a CFC, and coping accounted for 32% of the variance in satisfaction with past surgeries (P < 0.001). Youth age, sex, and assessment of condition severity were not significantly associated with satisfaction with surgical outcome. Depression, self-esteem, and negative consequences of having a CFC were not associated with satisfaction with past surgeries. Youth should be actively involved in the decision for craniofacial surgery. Youth who were more satisfied with their surgical outcomes also viewed themselves as having gained from the experience of living with a CFC. They felt that having a CFC made them stronger people and they believed that they were more accepting of others and more in touch with others' feelings because of what they had been through.

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

    PubMed Central

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

    2016-01-01

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

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

    PubMed

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

    2016-10-01

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

  11. 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.

  12. Clinical holistic medicine: factors influencing the therapeutic decision-making. From academic knowledge to emotional intelligence and spiritual "crazy" wisdom.

    PubMed

    Ventegodt, Søren; Kandel, Isack; Merrick, Joav

    2007-12-10

    Scientific holistic medicine is built on holistic medical theory, on therapeutic and ethical principles. The rationale is that the therapist can take the patient into a state of salutogenesis, or existential healing, using his skills and knowledge. But how ever much we want to make therapy a science it remains partly an art, and the more developed the therapist becomes, the more of his/her decisions will be based on intuition, feeling and even inspiration that is more based on love and human concern and other spiritual motivations than on mental reason and rationality in a simple sense of the word. The provocative and paradoxal medieval western concept of the "truth telling clown", or the eastern concepts of "crazy wisdom" and "holy madness" seems highly relevant here. The problem is how we can ethically justify this kind of highly "irrational" therapeutic behavior in the rational setting of a medical institution. We argue here that holistic therapy has a very high success rate and is doing no harm to the patient, and encourage therapists, psychiatrists, psychologist and other academically trained "helpers" to constantly measure their own success-rate. This paper discusses many of the important factors that influence clinical holistic decision-making. Sexuality could, as many psychoanalysts from Freud to Reich and Searles have believed, be the most healing power that exists and also the most difficult for the mind to comprehend, and thus the most "crazy-wise" tool of therapy.

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

    PubMed

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

    2007-10-15

    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. 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. 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

  14. 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

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

    PubMed

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

    2012-12-01

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

  16. Children's knowledge and degree of participation in decision making when undergoing a clinical diagnostic procedure.

    PubMed

    Runeson, Ingrid; Mårtenson, Eva; Enskär, Karin

    2007-01-01

    Twenty-three children, (6-11 years, 9 boys and 14 girls), admitted to a pediatric day care department for a planned diagnostic procedure were interviewed with the aim of investigating their level of knowledge regarding a current diagnostic procedure, and the level of participation in discussions and decision making relating to their hospitalization. While the children were being interviewed, their attendant parent completed a questionnaire. The children's level of knowledge was documented and graded. The children's statements and their parents' evaluation of the information given to the child were sorted into groups and compared. The children's descriptions of their participation in discussions and decision-making were assessed and summarized. Finally, the children's and their parents' experiences of the children's anxiety and fear before the hospital visit were compared. The children were undergoing different kinds of diagnostic procedures and they had received information from different people. They were prepared for their admission in different ways, and had participated in discussions and decisions to various degrees. Despite this preparation, it would be safe to state that the participants as a group were not very well informed nor did they participate fully. More knowledge is needed regarding how to prepare each child prior to admission, before, during, and after the hospital visit and which additional factors, e.g., trust and a familiar environment, have influence on the child's experience.

  17. [On the importance of the "decision-making model" view of diagnosis as a clinical framework in psychiatry].

    PubMed

    Ota, T

    2000-01-01

    After the advent of DSM-III, operational diagnostic criteria, along with the classification of disorders using such criteria, received considerable attention, and many studies on the reliability and validity of psychiatric diagnosis were conducted worldwide. Operational methodology was applied to diagnosis and classification, especially, in the area of research, and has contributed greatly to advances in reliable and refined clinical research. Such methodology, however, has not necessarily been accepted as a guiding principle in the area of clinical practice by all psychiatrists. Rather, some psychiatrists, especially more experienced psychiatrists, took a somewhat negative attitude toward the use of operational methodology. The author contends that one of the causes for the relatively poor acceptance of operational methodology in the area of clinical practice lies in the "classification model" view of diagnosis that forms the implicit background for the methodology. From a clinical perspective, it is not from the "classification model" basis but rather, from the "decision-making model" basis that the actual process of clinical diagnosis in psychiatry is explained properly. This is a very important point, because the latter model is potentially more useful both to psychiatric patients and to researchers in psychiatry than the former model. There have been however, few reports in psychiatry that highlight the importance of this model as the clinical framework. The author analyzes the limitations of the "classification model" view, and then, based on this analysis, lists prerequisites that a model for the framework of clinical practice should possess. The prerequisites listed are: that clinical information not sufficient to meet the disease criteria should be used as effectively as possible, that diseases low in probability but high in seriousness should be considered by clinicians in the differential diagnoses; that diagnosis should be readily changed when necessary

  18. 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

  19. Physician trainees' decision making and information processing: choice size and Medicare Part D.

    PubMed

    Barnes, Andrew J; Hanoch, Yaniv; Martynenko, Melissa; Wood, Stacey; Rice, Thomas; Federman, Alex D

    2013-01-01

    Many patients expect their doctor to help them choose a Medicare prescription drug plan. Whether the size of the choice set affects clinicians' decision processes and strategy selection, and the quality of their choice, as it does their older patients, is an important question with serious financial consequences. Seventy medical students and internal medicine residents completed a within-subject design using Mouselab, a computer program that allows the information-acquisition process to be examined. We examined highly numerate physician trainees' decision processes, strategy, and their ability to pick the cheapest drug plan-as price was deemed the most important factor in Medicare beneficiaries' plan choice-from either 3 or 9 drug plans. Before adjustment, participants were significantly more likely to identify the lowest cost plan when facing three versus nine choices (67.3% vs. 32.8%, p<0.01) and paid significantly less in excess premiums ($60.00 vs. $128.51, p<0.01). Compared to the three-plan condition, in the nine-plan condition participants spent significantly less time acquiring information on each attribute (p<0.05) and were more likely to employ decision strategies focusing on comparing alternate plans across a single attribute (search pattern, p<0.05). After adjusting for decision process and strategy, numeracy, and amount of medical training, the odds were 10.75 times higher that trainees would choose the lowest cost Medicare Part D drug plan when facing 3 versus 9 drug plans (p<0.05). Although employing more efficient search strategies in the complex choice environment, physician trainees experienced similar difficulty in choosing the lowest cost prescription drug plans as older patients do. Our results add further evidence that simplifications to the Medicare Part D decision environment are needed and suggest physicians' role in their patients' Part D choices may be most productive when assisting seniors with forecasting their expected medication needs

  20. 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…

  1. 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…

  2. 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.

  3. 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

  4. Using evidence-based algorithms to improve clinical decision making: the case of a first-time anterior shoulder dislocation.

    PubMed

    Federer, Andrew E; Taylor, Dean C; Mather, Richard C

    2013-09-01

    Decision making in health care has evolved substantially over the last century. Up until the late 1970s, medical decision making was predominantly intuitive and anecdotal. It was based on trial and error and involved high levels of problem solving. The 1980s gave way to empirical medicine, which was evidence based probabilistic, and involved pattern recognition and less problem solving. Although this represented a major advance in the quality of medical decision making, limitations existed. The advantages of the gold standard of the randomized controlled clinical trial (RCT) are well-known and this technique is irreplaceable in its ability to answer critical clinical questions. However, the RCT does have drawbacks. RCTs are expensive and can only capture a snapshot in time. As treatments change and new technologies emerge, new expensive clinical trials must be undertaken to reevaluate them. Furthermore, in order to best evaluate a single intervention, other factors must be controlled. In addition, the study population may not match that of another organization or provider. Although evidence-based medicine has provided powerful data for clinicians, effectively and efficiently tailoring it to the individual has not yet evolved. We are now in a period of transition from this evidence-based era to one dominated by the personalization and customization of care. It will be fueled by policy decisions to shift financial responsibility to the patient, creating a powerful and sophisticated consumer, unlike any patient we have known before. The challenge will be to apply medical evidence and personal preferences to medical decisions and deliver it efficiently in the increasingly busy clinical setting. In this article, we provide a robust review of the concepts of customized care and some of techniques to deliver it. We will illustrate this through a personalized decision model for the treatment decision after a first-time anterior shoulder dislocation.

  5. Views of older persons with multiple morbidities on competing outcomes and clinical decision-making.

    PubMed

    Fried, Terri R; McGraw, Sarah; Agostini, Joseph V; Tinetti, Mary E

    2008-10-01

    To examine the ways in which older persons with multiple conditions think about potentially competing outcomes in order to gain insight into how processes to elicit values regarding these outcomes can be grounded in the patient's perspective. Qualitative study consisting of purposefully sampled focus groups. Community. Persons aged 65 and older taking five or more medications. Participants were asked their perceptions about whether their illnesses or treatment interacted with each other, goals of their treatment, and decisions to change or stop treatment. Although participants were largely unaware that treatment of one condition could worsen another, many had experience with adverse medication effects as a competing outcome. Participants initially discussed their conditions in terms of disease-specific outcomes, such as achieving a target blood pressure or lipid level. In the context of decision-making, participants shifted their discussion from disease-specific to global, cross-disease health outcomes, such as survival, preservation of physical function, and relief of symptoms. Despite having some misconceptions regarding the likelihood of these outcomes, they weighed the outcomes against one another to consider what was most important to them. Their preference was for the treatment that would achieve the most desired outcome. Because of their experience with adverse medication effects, older persons with multiple morbidities can understand the concept of competing outcomes. The task of prioritizing global, cross-disease outcomes can help to clarify what is most important to seniors who are faced with complex healthcare decisions.

  6. Views of Older Persons with Multiple Morbidities on Competing Outcomes and Clinical Decision-Making

    PubMed Central

    Fried, Terri R.; McGraw, Sarah; Agostini, Joseph V.; Tinetti, Mary E.

    2008-01-01

    Objectives: To examine the ways in which older persons with multiple conditions think about potentially competing outcomes, in order to gain insight into how processes to elicit values regarding these outcomes can be grounded in the patient's perspective. Design: Qualitative study consisting of purposefully sampled focus groups. Setting: Community Participants: Persons age ≥ 65 years taking ≥ 5 medications. Measurements: Participants were asked their perceptions about whether their illnesses or treatment interacted with each other, goals of their treatment, and decisions to change or stop treatment. Results: Although participants were largely unaware that treatment of one condition could worsen another, many had experience with adverse medication effects as a competing outcome. Participants initially discussed their conditions in terms of disease-specific outcomes, such as achieving a target blood pressure or lipid level. In the context of decision-making, participants shifted their discussion from disease-specific to global, cross-disease health outcomes, such as survival, preservation of physical function, and relief of symptoms. Despite having some misconceptions regarding the likelihood of these outcomes, they weighed the outcomes against one another in order to consider what was most important to them. Their preference was for the treatment that would achieve the most desired outcome. Conclusions: Because of their experience with adverse medication effects, older persons with multiple morbidities can understand the concept of competing outcomes. The task of prioritizing global, cross-disease outcomes can help to clarify what is most important to seniors who are faced with complex healthcare decisions. PMID:18771453

  7. [Concordance and usefulness of a stratification system for clinical decision making].

    PubMed

    González González, Ana Isabel; Miquel Gómez, Ana María; Rodríguez Morales, David; Hernández Pascual, Montserrat; Sánchez Perruca, Luis; Mediavilla Herrera, Inmaculada

    2017-04-01

    1) To analyse concordance between the level of risk classification using the Adjusted Groups Morbidity (GMA) tool and the assigned level of intervention by general practitioners (GP). 2) To study the usefulness of the GMA tool as an aid in electronic medical records (EMR) for decision making. Cross-sectional observational study of concordance. Primary Care. Madrid Health Service. Twenty eight GPs. A sample of 840 patients assigned to participating GPs was selected by disproportionate stratified random sampling (0.65 kappa, 0.125 precision, 5% positive rate, 95% confidence level). Weighted Cohen Kappa index for the degree of concordance between the GMA tool and the GPs. The usefulness of the tool was assessed using an ad hoc developed questionnaire. Kappa weighted index obtained was 0.60 (95%CI: 0.55-0.65). In 3% of cases the disagreement was maximum. The GPs found that the grouping tool had been useful in 76% of cases. Moderate strength/good concordance; incorporating a grouping tool in the EMR helps as a reminder for taking more proactive/integrated decisions based on social and health needs of people with chronic diseases. Copyright © 2016 Elsevier España, S.L.U. All rights reserved.

  8. An agenda for clinical decision making and judgement in nursing research and education.

    PubMed

    Thompson, Carl; Aitken, Leanne; Doran, Diane; Dowding, Dawn

    2013-12-01

    Nurses' judgements and decisions have the potential to help healthcare systems allocate resources efficiently, promote health gain and patient benefit and prevent harm. Evidence from healthcare systems throughout the world suggests that judgements and decisions made by clinicians could be improved: around half of all adverse events have some kind of error at their core. For nursing to contribute to raising quality though improved judgements and decisions within health systems we need to know more about the decisions and judgements themselves, the interventions likely to improve judgement and decision processes and outcomes, and where best to target finite intellectual and educational resources. There is a rich heritage of research into decision making and judgement, both from within the discipline of nursing and from other perspectives, but which focus on nurses. Much of this evidence plays only a minor role in the development of educational and technological efforts at decision improvement. This paper presents nine unanswered questions that researchers and educators might like to consider as a potential agenda for the future of research into this important area of nursing practice, training and development.

  9. DIFFERENTIAL DIAGNOSTIC PROCESS AND CLINICAL DECISION MAKING IN A YOUNG ADULT FEMALE WITH LATERAL HIP PAIN: A CASE REPORT.

    PubMed

    Livingston, Jennifer I; Deprey, Sara M; Hensley, Craig P

    2015-10-01

    differential diagnosis and clinical decision making. Young adults with lateral hip pain are often referred to physical therapy (PT). A thorough examination is required to obtain a diagnosis and guide management. The purpose of this case report is to describe the physical therapist's differential diagnostic process and clinical decision making for a subject with the referring diagnosis of trochanteric bursitis. A 29-year-old female presented to PT with limited sitting and running tolerance secondary to right lateral hip pain. Her symptoms began three months prior when she abruptly changed her running intensity and frequency of weight bearing activities, including running and low impact plyometrics for the lower extremity. Physical examination revealed a positive Trendelenburg sign, manual muscle test that was weak and painless of the right hip abductors, and pain elicited when performing a vertical hop on a concrete surface (+single leg hop test), but pain-free when performing the same single leg hop on a foam surface. Examination findings warranted discussion with the referring physician for further diagnostic imaging. Magnetic resonance imaging revealed a focus of edema in the posterior acetabulum, suspicious for an acetabular stress fracture. The subject was subsequently diagnosed with an acetabular stress fracture and restricted from running and plyometrics for four weeks. Thorough examination and appropriate clinical decision making by the physical therapist at the initial examination led to the diagnosis of an acetabular stress fracture in this subject. Clinicians must be aware of symptoms and signs which place the subject at risk for stress fracture for timely referral and management. 4.

  10. Innovative solutions: using case studies to generate increased nurse's clinical decision-making ability in critical care.

    PubMed

    Grossman, Sheila; Krom, Zachary R; O'Connor, Rick

    2010-01-01

    Learning to care for critically ill patients requires a high level of critical thinking, clinical decision-making ability, and a substantial knowledge base. At this nursing school, an elective Critical Care Nursing course for last-semester seniors was designed to include active learning strategies, focusing on the use of case studies to facilitate learning. Results indicate significantly improved final examination scores for those involved with the case-study pedagogy. In addition, students identified enhanced communication skills. Two complex cases are presented for others to use with their educational programs.

  11. Critical thinking about adverse drug effects: lessons from the psychology of risk and medical decision-making for clinical psychopharmacology.

    PubMed

    Nierenberg, Andrew A; Smoller, Jordan W; Eidelman, Polina; Wu, Yelena P; Tilley, Claire A

    2008-01-01

    Systematic biases in decision-making have been well characterized in medical and nonmedical fields but mostly ignored in clinical psychopharmacology. The purpose of this paper is to sensitize clinicians who prescribe psychiatric drugs to the issues of the psychology of risk, especially as they pertain to the risk of side effects. Specifically, the present analysis focuses on heuristic organization and framing effects that create cognitive biases in medical practice. Our purpose is to increase the awareness of how pharmaceutical companies may influence physicians by framing the risk of medication side effects to favor their products.

  12. By-person factor analysis in clinical ethical decision making: Q methodology in end-of-life care decisions.

    PubMed

    Wong, William; Eiser, Arnold R; Mrtek, Robert G; Heckerling, Paul S

    2004-01-01

    To determine the usefulness of Q methodology to locate and describe shared subjective influences on clinical decision making among participant physicians using hypothetical cases containing common ethical issues. Qualitative study using by-person factor analysis of subjective Q sort data matrix. University medical center. Convenience sample of internal medicine attending physicians and house staff (n = 35) at one midwestern academic health sciences center. Presented with four hypothetical cases involving urgent decision making near the end of life, participants selected one of three specific clinical actions offered for each case. Immediately afterward and while considering their decision, each respondent sorted twenty-five subjective self-referent items in terms of the influence of each statement on their decision-making process. By-person factor analysis, where participants are defined as variates, yielded information about the attitudinal background the physicians brought to their consideration of each hypothetical case. We performed a second-order factor analysis on all of the subjective viewpoints to determine if a smaller core of shared attitudes existed across some or all of the four case vignettes. Factor scores for each item and post-sort comments from interviews conducted individually with each respondent guided the interpretation of ethical perspective used by these respondents in making clinical decisions about the cases. Second-order factor analysis on seventeen viewpoints used by physicians in the four hypothetical urgent decision cases revealed three moderately correlated (r2 < 40%) subjective core attitudinal guides used broadly among all the cases and among sixteen of the seventeen original factors. Across all the cases, our participants were guided in general by: (1) patient-focused beneficence, (2) a patient- and surrogate-focused perspective that includes risk avoidance, and (3) best interest of the patient guided by ethical values. Economic

  13. Development and psychometric properties of a five-language multiperspective instrument to assess clinical decision making style in the treatment of people with severe mental illness (CDMS).

    PubMed

    Puschner, Bernd; Neumann, Petra; Jordan, Harriet; Slade, Mike; Fiorillo, Andrea; Giacco, Domenico; Egerházi, Anikó; Ivánka, Tibor; Bording, Malene Krogsgaard; Sørensen, Helle Østermark; Bär, Arlette; Kawohl, Wolfram; Loos, Sabine

    2013-02-04

    The aim of this study was to develop and evaluate psychometric properties of the Clinical Decision Making Style (CDMS) scale which measures general preferences for decision making as well as preferences regarding the provision of information to the patient from the perspectives of people with severe mental illness and staff. A participatory approach was chosen for instrument development which followed 10 sequential steps proposed in a current guideline of good practice for the translation and cultural adaptation of measures. Following item analysis, reliability, validity, and long-term stability of the CDMS were examined using Spearman correlations in a sample of 588 people with severe mental illness and 213 mental health professionals in 6 European countries (Germany, UK, Italy, Denmark, Hungary, and Switzerland). In both patient and staff versions, the two CDMS subscales "Participation in Decision Making" and "Information" reliably measure distinct characteristics of decision making. Validity could be demonstrated to some extent, but needs further investigation. Together with two other five-language patient- and staff-rated measures developed in the CEDAR study (ISRCTN75841675) - "Clinical Decision Making in Routine Care" and "Clinical Decision Making Involvement and Satisfaction" - the CDMS allows empirical investigation of the complex relation between clinical decision making and outcome in the treatment of people with severe mental illness across Europe.

  14. Prevalence of clinically significant decisional conflict: an analysis of five studies on decision-making in primary care

    PubMed Central

    Thompson-Leduc, Philippe; Turcotte, Stéphane; Labrecque, Michel; Légaré, France

    2016-01-01

    Objectives Unresolved clinically significant decisional conflict (CSDC) in patients following a consultation with health professionals is often the result of inadequate patient involvement in decision-making and may result in poor outcomes. We sought to identify the prevalence of CSDC in studies on decision-making in primary care and to explore its risk factors. Setting We performed a secondary analysis of existing data sets from studies conducted in Primary Care Practice-Based Research Networks in Québec and Ontario, Canada. Participants Eligible studies included a patient-reported measure on the 16-item Decisional Conflict Scale (DCS) following a decision made with a healthcare professional with no study design restriction. Primary and secondary outcome measures CSDC was defined as a score ≥25/100 on the DCS. The prevalence of CSDC was stratified by sex; and patient-level logistic regression analysis was performed to explore its potential risk factors. Data sets of studies were analysed individually and qualitatively compared. Results 5 projects conducted between 2003 and 2010 were included. They covered a range of decisions: prenatal genetic screening, antibiotics for acute respiratory infections and miscellaneous. Altogether, the 5 projects gathered data from encounters with a total of 1338 primary care patients (69% female; range of age 15–83). The prevalence of CSDC in patients varied across studies and ranged from 10.3% (95% CI 7.2% to 13.4%) to 31.1% (95% CI 26.6% to 35.6%). Across the 5 studies, risk factors of CSDC included being male, living alone and being 45 or older. Conclusions Prevalence of CSDC in patients who had enrolled in studies conducted in primary care contexts was substantial and appeared to vary according to the type of decision as well as to patient characteristics such as sex, living arrangement and age. Patients presenting risk factors of CSDC should be offered tools to increase their involvement in decision-making. PMID:27354076

  15. Connecting philosophy and practice: implications of two philosophic approaches to pain for nurses' expert clinical decision making.

    PubMed

    Pesut, Barbara; McDonald, Heather

    2007-10-01

    McCaffery's definition of pain as 'whatever the patient says it is' was truly revolutionary for nursing because of its capacity to lend credibility to the patient's pain experience. However, this definition, still widely in use, represents a particular philosophic approach to pain that has limitations for nurses' expert clinical decision making. In this paper, we trace the evolution of explanations for pain and discuss two philosophic approaches to pain that are common today. The first approach, the externalist perceptual view of pain, considers pain as a perceptual experience, one that like any perceptual experience can be 'misperceived' by the person having the experience. The second approach, the non-representational view of pain, considers pain as a holistic experience, one where physical and existential aspects necessarily coincide. These two approaches, while both emphasizing the importance of believing the patient's expression, have different implications for clinical decision making. Only the first approach permits nurses to exercise the nuanced judgement that differentiates pain from other related conditions such as anxiety, suffering or meaninglessness.

  16. 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

    2017-02-15

    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.

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

    PubMed

    White, Krista A

    2014-01-01

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

  18. 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.

  19. Mentoring in the Clinical Setting to Improve Student Decision-Making Competence

    ERIC Educational Resources Information Center

    Stick-Mueller, Misty; Boesch, Ron; Silverman, Steven; Carpenter, Scott; Illingworth, Robert; Countryman, James

    2010-01-01

    Introduction: The physician-intern relationship can be difficult to develop. A new chiropractic intern in a teaching clinic undergoes a major transition from classroom to clinical practice and must learn to turn classroom knowledge into clinical application. The ability to start formulating clinical techniques and apply them on a patient is…

  20. Evaluation of a Shared Decision-Making Intervention on the Utilization of Evidence-Based Psychotherapy in a VA Outpatient PTSD Clinic.

    PubMed

    Hessinger, Jonathan D; London, Melissa J; Baer, Sheila M

    2017-03-13

    The Veterans Health Administration (VHA) has continued to emphasize the availability, access, and utilization of high quality mental health care particularly in the treatment of posttraumatic stress disorder (PTSD). While dissemination and availability of evidence-based psychotherapies (EBPs) have only increased, treatment engagement and utilization have continued to be oft-noted challenges. Administrators, researchers, and individual clinicians have continued to develop and explore novel systemic and individualized interventions to address these issues. Pilot studies utilizing shared decision-making models to aid in veteran treatment selection have demonstrated the impact this approach may have on selection of and engagement in EBPs for PTSD. Based on these promising studies, a Department of Veterans Affairs (VA) outpatient PTSD clinic began to implement a shared-decision making intervention as part of a clinic redesign. In seeking to evaluate the impact of this intervention, archival clinical data from 1,056 veterans were reviewed by the authors for rates of treatment selection, EBP initiation, session attendance, and EBP completion. Time elapsed from consult until EBP initiation was also computed by the authors. These variables were then compared on the basis of whether the veteran received the shared-decision making intervention. Veterans who received the intervention were more likely to select and thus initiate an EBP for PTSD sooner than veterans who did not receive this intervention. Veterans, whether receiving the intervention or not, did not differ in therapy session attendance and completion. Implications of these findings and directions for future study are further discussed. (PsycINFO Database Record

  1. Should we Google it? Resource use by internal medicine residents for point-of-care clinical decision making.

    PubMed

    Duran-Nelson, Alisa; Gladding, Sophia; Beattie, Jim; Nixon, L James

    2013-06-01

    To determine which resources residents use at the point-of-care (POC) for decision making, the drivers for selection of these resources, and how residents use Google/Google Scholar to answer clinical questions at the POC. In January 2012, 299 residents from three internal medicine residencies were sent an electronic survey regarding resources used for POC decision making. Resource use frequency and factors influencing choice were determined using descriptive statistics. Binary logistic regression analysis was performed to determine relationships between the independent variables. A total of 167 residents (56%) responded; similar numbers responded at each level of training. Residents most frequently reported using UpToDate and Google at the POC at least daily (85% and 63%, respectively), with speed and trust in the quality of information being the primary drivers of selection. Google, used by 68% of residents, was used primarily to locate Web sites and general information about diseases, whereas Google Scholar, used by 30% of residents, tended to be used for treatment and management decisions or locating a journal article. The findings suggest that internal medicine residents use UpToDate most frequently, followed by consultation with faculty and the search engines Google and Google Scholar; speed, trust, and portability are the biggest drivers for resource selection; and time and information overload appear to be the biggest barriers to resources such as Ovid MEDLINE. Residents frequently used Google and may benefit from further training in information management skills.

  2. Teaching clinical reasoning and decision-making skills to nursing students: Design, development, and usability evaluation of a serious game.

    PubMed

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

    2016-10-01

    Serious games (SGs) are a type of simulation technology that may provide nursing students with the opportunity to practice their clinical reasoning and decision-making skills in a safe and authentic environment. Despite the growing number of SGs developed for healthcare professionals, few SGs are video based or address the domain of home health care. This paper aims to describe the design, development, and usability evaluation of a video based SG for teaching clinical reasoning and decision-making skills to nursing students who care for patients with chronic obstructive pulmonary disease (COPD) in home healthcare settings. A prototype SG was developed. A unified framework of usability called TURF (Task, User, Representation, and Function) and SG theory were employed to ensure a user-centered design. The educational content was based on the clinical decision-making model, Bloom's taxonomy, and a Bachelor of Nursing curriculum. A purposeful sample of six participants evaluated the SG prototype in a usability laboratory. Cognitive walkthrough evaluations, a questionnaire, and individual interviews were used for the usability evaluation. The data were analyzed using qualitative deductive content analysis based on the TURF framework elements and related usability heuristics. The SG was perceived as being realistic, clinically relevant, and at an adequate level of complexity for the intended users. Usability issues regarding functionality and the user-computer interface design were identified. However, the SG was perceived as being easy to learn, and participants suggested that the SG could serve as a supplement to traditional training in laboratory and clinical settings. Using video based scenarios with an authentic COPD patient and a home healthcare registered nurse as actors contributed to increased realism. Using different theoretical approaches in the SG design was considered an advantage of the design process. The SG was perceived as being useful, usable, and

  3. Teachers' Grading Decision Making

    ERIC Educational Resources Information Center

    Isnawati, Ida; Saukah, Ali

    2017-01-01

    This study investigated teachers' grading decision making, focusing on their beliefs underlying their grading decision making, their grading practices and assessment types, and factors they considered in grading decision making. Two teachers from two junior high schools applying different curriculum policies in grade reporting in Indonesian…

  4. Composite collective decision-making

    PubMed Central

    Czaczkes, Tomer J.; Czaczkes, Benjamin; Iglhaut, Carolin; Heinze, Jürgen

    2015-01-01

    Individual animals are adept at making decisions and have cognitive abilities, such as memory, which allow them to hone their decisions. Social animals can also share information. This allows social animals to make adaptive group-level decisions. Both individual and collective decision-making systems also have drawbacks and limitations, and while both are well studied, the interaction between them is still poorly understood. Here, we study how individual and collective decision-making interact during ant foraging. We first gathered empirical data on memory-based foraging persistence in the ant Lasius niger. We used these data to create an agent-based model where ants may use social information (trail pheromones), private information (memories) or both to make foraging decisions. The combined use of social and private information by individuals results in greater efficiency at the group level than when either information source was used alone. The modelled ants couple consensus decision-making, allowing them to quickly exploit high-quality food sources, and combined decision-making, allowing different individuals to specialize in exploiting different resource patches. Such a composite collective decision-making system reaps the benefits of both its constituent parts. Exploiting such insights into composite collective decision-making may lead to improved decision-making algorithms. PMID:26019155

  5. Commentary: Should Pharmacogenomic Evidence Be Considered in Clinical Decision Making? Focus on Select Cardiovascular Drugs.

    PubMed

    Bottorff, Michael B; Bright, David R; Kisor, David F

    2017-09-01

    Despite advances in technology and guidelines from the Clinical Pharmacogenetics Implementation Consortium (CPIC) that focus on how to use pharmacogene test results, hurdles remain that have delayed the widespread application of pharmacogenomics in clinical practice. These hurdles include a lack of prospective randomized controlled trials to address the utility of pharmacogenomics on clinical outcomes, what the clinical algorithm for pharmacogenomics should be, and whether pharmacogenomics is cost-effective. However, the implementation of clinical practice guidelines, such as those from professional organizations, is commonplace and often termed the application of evidence-based medicine. Here, we draw an analogy between the evidence supporting many commonly cited clinical practice guidelines and U.S. Food and Drug Administration-approved labeling recommendations and the evidence supporting recommendations from CPIC. Although many clinical practice guideline recommendations are supported by the results of randomized controlled clinical trials, we cite examples of common clinical practices that are supported by levels and types of evidence similar to the evidence supporting many of the CPIC recommendations. Specifically, we discuss clinical recommendations for guidance related to drug-drug interactions, drug-gene interactions, therapeutic range selection, and dosage adjustments based on patient-specific factors within the context of a select set of cardiovascular therapeutic topics. © 2017 Pharmacotherapy Publications, Inc.

  6. Recommendations for Standardizing Glucose Reporting and Analysis to Optimize Clinical Decision Making in Diabetes: The Ambulatory Glucose Profile

    PubMed Central

    Bergenstal, Richard M.; Ahmann, Andrew J.; Bailey, Timothy; Beck, Roy W.; Bissen, Joan; Buckingham, Bruce; Deeb, Larry; Dolin, Robert H.; Garg, Satish K.; Goland, Robin; Hirsch, Irl B.; Klonoff, David C.; Kruger, Davida F.; Matfin, Glenn; Mazze, Roger S.; Olson, Beth A.; Parkin, Christopher; Peters, Anne; Powers, Margaret A.; Rodriguez, Henry; Southerland, Phil; Strock, Ellie S.; Tamborlane, William; Wesley, David M.

    2013-01-01

    Underutilization of glucose data and lack of easy and standardized glucose data collection, analysis, visualization, and guided clinical decision making are key contributors to poor glycemic control among individuals with type 1 diabetes mellitus. An expert panel of diabetes specialists, facilitated by the International Diabetes Center and sponsored by the Helmsley Charitable Trust, met in 2012 to discuss recommendations for standardizing the analysis and presentation of glucose monitoring data, with the initial focus on data derived from continuous glucose monitoring systems. The panel members were introduced to a universal software report, the Ambulatory Glucose Profile, and asked to provide feedback on its content and functionality, both as a research tool and in clinical settings. This article provides a summary of the topics and issues discussed during the meeting and presents recommendations from the expert panel regarding the need to standardize glucose profile summary metrics and the value of a uniform glucose report to aid clinicians, researchers, and patients. PMID:23567014

  7. Preserving residual renal function in dialysis patients: an update on evidence to assist clinical decision making

    PubMed Central

    Jensen, Jens Dam; Peters, Christian Daugaard; Jespersen, Bente

    2011-01-01

    It has been documented that preservation of residual renal function in dialysis patients improves quality of life as well as survival. Clinical trials on strategies to preserve residual renal function are clearly lacking. While waiting for more results from clinical trials, patients will benefit from clinicians being aware of available knowledge. The aim of this review was to offer an update on current evidence assisting doctors in clinical practice. PMID:25949486

  8. Does electronic clinical microbiology results reporting influence medical decision making: a pre- and post-interview study of medical specialists

    PubMed Central

    2011-01-01

    Background Clinicians view the accuracy of test results and the turnaround time as the two most important service aspects of the clinical microbiology laboratory. Because of the time needed for the culturing of infectious agents, final hardcopy culture results will often be available too late to have a significant impact on early antimicrobial therapy decisions, vital in infectious disease management. The clinical microbiologist therefore reports to the clinician clinically relevant preliminary results at any moment during the diagnostic process, mostly by telephone. Telephone reporting is error prone, however. Electronic reporting of culture results instead of reporting on paper may shorten the turnaround time and may ensure correct communication of results. The purpose of this study was to assess the impact of the implementation of electronic reporting of final microbiology results on medical decision making. Methods In a pre- and post-interview study using a semi-structured design we asked medical specialists in our hospital about their use and appreciation of clinical microbiology results reporting before and after the implementation of an electronic reporting system. Results Electronic reporting was highly appreciated by all interviewed clinicians. Major advantages were reduction of hardcopy handling and the possibility to review results in relation to other patient data. Use and meaning of microbiology reports differ significantly between medical specialties. Most clinicians need preliminary results for therapy decisions quickly. Therefore, after the implementation of electronic reporting, telephone consultation between clinician and microbiologist remained the key means of communication. Conclusions Overall, electronic reporting increased the workflow efficiency of the medical specialists, but did not have an impact on their decision-making. PMID:21447199

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

    ERIC Educational Resources Information Center

    Greer, Marianne L.; Kirk, Kenneth W.

    1988-01-01

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

  10. The amygdala and decision making

    PubMed Central

    Gupta, Rupa; Koscik, Timothy R.; Bechara, Antoine; Tranel, Daniel

    2010-01-01

    Decision-making is a complex process that requires the orchestration of multiple neural systems. For example, decision-making is believed to involve areas of the brain involved in emotion (e.g., amygdala, ventromedial prefrontal cortex) and memory (e.g., hippocampus, dorsolateral prefrontal cortex). In this article, we will present findings related to the amygdala’s role in decision-making, and differentiate the contributions of the amygdala from those of other structurally and functionally connected neural regions. Decades of research have shown that the amygdala is involved in associating a stimulus with its emotional value. This tradition has been extended in newer work, which has shown that the amygdala is especially important for decision-making, by triggering autonomic responses to emotional stimuli, including monetary reward and punishment. Patients with amygdala damage lack these autonomic responses to reward and punishment, and consequently, cannot utilize “somatic marker” type cues to guide future decision-making. Studies using laboratory decision-making tests have found deficient decision-making in patients with bilateral amygdala damage, which resembles their real-world difficulties with decision-making. Additionally, we have found evidence for an interaction between sex and laterality of amygdala functioning, such that unilateral damage to the right amygdala results in greater deficits in decision-making and social behavior in men, while left amygdala damage seems to be more detrimental for women. We have posited that the amygdala is part of an “impulsive,” habit type system that triggers emotional responses to immediate outcomes. PMID:20920513

  11. Diagnostic thinking and information used in clinical decision-making: a qualitative study of expert and student dental clinicians

    PubMed Central

    2010-01-01

    Background It is uncertain whether the range and frequency of Diagnostic Thinking Processes (DTP) and pieces of information (concepts) involved in dental restorative treatment planning are different between students and expert clinicians. Methods We video-recorded dental visits with one standardized patient. Clinicians were subsequently interviewed and their cognitive strategies explored using guide questions; interviews were also recorded. Both visit and interview were content-analyzed, following the Gale and Marsden model for clinical decision-making. Limited tests used to contrast data were t, χ2, and Fisher's. Scott's π was used to determine inter-coder reliability. Results Fifteen dentists and 17 senior dental students participated in visits lasting 32.0 minutes (± 12.9) among experts, and 29.9 ± 7.1 among students; contact time with patient was 26.4 ± 13.9 minutes (experts), and 22.2 ± 7.5 (students). The time elapsed between the first and the last instances of the clinician looking in the mouth was similar between experts and students. Ninety eight types of pieces of information were used in combinations with 12 DTPs. The main differences found in DTP utilization had dentists conducting diagnostic interpretations of findings with sufficient certainty to be considered definitive twice as often as students. Students resorted more often to more general or clarifying enquiry in their search for information than dentists. Conclusions Differences in diagnostic strategies and concepts existed within clearly delimited types of cognitive processes; such processes were largely compatible with the analytic and (in particular) non-analytic approaches to clinical decision-making identified in the medical field. Because we were focused on a clinical presentation primarily made up of non-emergency treatment needs, use of other DTPs and concepts might occur when clinicians evaluate emergency treatment needs, complex rehabilitative cases, and/or medically compromised

  12. ‘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

  13. '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

    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

    2013-10-01

    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. 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. 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). 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. 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. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

  14. Categorization = Decision Making + Generalization

    PubMed Central

    Seger, Carol A; Peterson, Erik J.

    2013-01-01

    We rarely, if ever, repeatedly encounter exactly the same situation. This makes generalization crucial for real world decision making. We argue that categorization, the study of generalizable representations, is a type of decision making, and that categorization learning research would benefit from approaches developed to study the neuroscience of decision making. Similarly, methods developed to examine generalization and learning within the field of categorization may enhance decision making research. We first discuss perceptual information processing and integration, with an emphasis on accumulator models. We then examine learning the value of different decision making choices via experience, emphasizing reinforcement learning modeling approaches. Next we discuss how value is combined with other factors in decision making, emphasizing the effects of uncertainty. Finally, we describe how a final decision is selected via thresholding processes implemented by the basal ganglia and related regions. We also consider how memory related functions in the hippocampus may be integrated with decision making mechanisms and contribute to categorization. PMID:23548891

  15. Nurse practitioner clinical decision-making and evidence-based practice.

    PubMed

    Vincent, Deborah; Hastings-Tolsma, Marie; Gephart, Sheila; Alfonzo, Paige M

    2015-05-15

    Evidence-based practice is key to improving patient outcomes but can be challenging for busy nurse practitioners to implement. This article describes the process of critically appraising evidence for use in clinical practice and offers strategies for implementing evidence-based innovations and disseminating the findings.

  16. Myocardial strain imaging: how useful is it in clinical decision making?

    PubMed Central

    Smiseth, Otto A.; Torp, Hans; Opdahl, Anders; Haugaa, Kristina H.; Urheim, Stig

    2016-01-01

    Myocardial strain is a principle for quantification of left ventricular (LV) function which is now feasible with speckle-tracking echocardiography. The best evaluated strain parameter is global longitudinal strain (GLS) which is more sensitive than left ventricular ejection fraction (LVEF) as a measure of systolic function, and may be used to identify sub-clinical LV dysfunction in cardiomyopathies. Furthermore, GLS is recommended as routine measurement in patients undergoing chemotherapy to detect reduction in LV function prior to fall in LVEF. Intersegmental variability in timing of peak myocardial strain has been proposed as predictor of risk of ventricular arrhythmias. Strain imaging may be applied to guide placement of the LV pacing lead in patients receiving cardiac resynchronization therapy. Strain may also be used to diagnose myocardial ischaemia, but the technology is not sufficiently standardized to be recommended as a general tool for this purpose. Peak systolic left atrial strain is a promising supplementary index of LV filling pressure. The strain imaging methodology is still undergoing development, and further clinical trials are needed to determine if clinical decisions based on strain imaging result in better outcome. With this important limitation in mind, strain may be applied clinically as a supplementary diagnostic method. PMID:26508168

  17. Myocardial strain imaging: how useful is it in clinical decision making?

    PubMed

    Smiseth, Otto A; Torp, Hans; Opdahl, Anders; Haugaa, Kristina H; Urheim, Stig

    2016-04-14

    Myocardial strain is a principle for quantification of left ventricular (LV) function which is now feasible with speckle-tracking echocardiography. The best evaluated strain parameter is global longitudinal strain (GLS) which is more sensitive than left ventricular ejection fraction (LVEF) as a measure of systolic function, and may be used to identify sub-clinical LV dysfunction in cardiomyopathies. Furthermore, GLS is recommended as routine measurement in patients undergoing chemotherapy to detect reduction in LV function prior to fall in LVEF. Intersegmental variability in timing of peak myocardial strain has been proposed as predictor of risk of ventricular arrhythmias. Strain imaging may be applied to guide placement of the LV pacing lead in patients receiving cardiac resynchronization therapy. Strain may also be used to diagnose myocardial ischaemia, but the technology is not sufficiently standardized to be recommended as a general tool for this purpose. Peak systolic left atrial strain is a promising supplementary index of LV filling pressure. The strain imaging methodology is still undergoing development, and further clinical trials are needed to determine if clinical decisions based on strain imaging result in better outcome. With this important limitation in mind, strain may be applied clinically as a supplementary diagnostic method. © The Author 2015. Published by Oxford University Press on behalf of the European Society of Cardiology.

  18. Calibrating for Comorbidity: Clinical Decision-Making in Youth Depression and Anxiety

    ERIC Educational Resources Information Center

    Chu, Brian C.; Merson, Rachel A.; Zandberg, Laurie J.; Areizaga, Margaret

    2012-01-01

    Comorbidity in clinical youth populations is more the rule than the exception, yet few established guidelines exist to help practicing clinicians manage complex diagnostic profiles. The current paper reviews efforts within the treatment development literature to handle comorbidity in depressed and anxious children and adolescents, including…

  19. Calibrating for Comorbidity: Clinical Decision-Making in Youth Depression and Anxiety

    ERIC Educational Resources Information Center

    Chu, Brian C.; Merson, Rachel A.; Zandberg, Laurie J.; Areizaga, Margaret

    2012-01-01

    Comorbidity in clinical youth populations is more the rule than the exception, yet few established guidelines exist to help practicing clinicians manage complex diagnostic profiles. The current paper reviews efforts within the treatment development literature to handle comorbidity in depressed and anxious children and adolescents, including…

  20. Review article: recent insights into clinical decision-making in severe alcoholic hepatitis.

    PubMed

    Dunne, P D J; Forrest, E H

    2017-08-01

    Alcoholic hepatitis is a severe acute manifestation of alcoholic liver disease with a high mortality. Management of patients with this condition has been a matter of controversy for many years; however, recent clinical studies have sought to improve the clinical approach to these patients. To use these recent studies in order to guide clinical management. A MeSH search of Medline was performed to specifically identify recent studies which influenced clinical diagnosis, assessment and management of alcoholic hepatitis. Fulfilment of clear clinical criteria including a minimum threshold of bilirubin, defined periods of jaundice and alcohol ingestion negates the need for liver biopsy in most patients. Corticosteroids improve short-term mortality only (28 day) with other factors such as abstinence likely to be significant in long-term outcome. Pentoxifylline is not an effective treatment. The Glasgow Alcoholic Hepatitis Score (GAHS) score can identify those patients likely to benefit from corticosteroids, but scores that include the evolution of bilirubin over 1 week of such treatment (such as the Lille Score) define "response". Underlying infection may contribute towards corticosteroid nonresponse and needs to be actively sought out and treated. Liver transplant remains controversial; however, it has been shown to be feasible in alcoholic hepatitis. Recent studies have helped to define patients who may benefit from corticosteroid treatment. However, there remains a need for more accurate scores of prognosis and treatment response, and a clear need for alternative treatments for those patients not responding to corticosteroid therapy. © 2017 Crown copyright. Alimentary Pharmacology and Therapeutics © 2017 John Wiley & Sons Ltd.

  1. Does gait analysis change clinical decision-making in poststroke patients? Results from a pragmatic prospective observational study.

    PubMed

    Ferrarin, M; Rabuffetti, M; Bacchini, M; Casiraghi, A; Castagna, A; Pizzi, A; Montesano, A

    2015-04-01

    Gait analysis (GA) was demonstrated to change presurgical planning and improve gait outcomes in children with Cerebral Palsy. GA is often used also to assess walking capability of poststroke subjects, although its influence in the clinical management of these patients has not yet been established. To assess the impact of GA on clinical decision-making in adult chronic poststroke patients. Pragmatic prospective observational study. Rehabilitation hospital, both outpatients and inpatients. Forty-nine patients (age: 53.3±14.5 years) who had had a cerebrovascular accident 35.2±26.4 months before and were referred to the gait analysis service. Recommendations of therapeutic treatments before and after the analysis of GA data were compared, together with the confidence level of recommendations on a 10-point scale. Frequency of changes of post-GA vs pre-GA recommendations were computed for each recommendation type: surgery, botulinum toxin (BT), orthotic management and physiotherapy. Based on the analysis of GA data, 71% of poststroke subjects had their treatment planning changed in some components. Indeed, 73% of patients with indications for surgery had their surgical planning changed; 81%, 37% and 32% had, respectively, their BT, orthotic and physiotherapy planning changed. Confidence level of recommendations increased significantly after GA, in both the whole group of patients (from 6.7±1.4 to 8.7±0.6, P<0.01) and the subgroup whose recommendations had not changed (7.0±1.5 vs. 8.8±0.4, P<0.01). GA significantly influences the therapeutic planning and reinforces decision-making for chronic poststroke patients. Further work should be done to better translate GA results into indications for specific physiotherapy. The use of GA as a tool to better define the rehabilitation planning in post-stroke patients should be fostered, particularly when surgery or botulinum toxin are considered and/or the prescription of orthoses is hypothesised.

  2. Why Current PTH Assays Mislead Clinical Decision Making in Patients with Secondary Hyperparathyroidism.

    PubMed

    Hocher, Berthold; Yin, Lianghong

    2017-02-10

    Preclinical studies in cell culture systems as well as in whole animal chronic kidney disease (CKD) models showed that parathyroid hormone (PTH), oxidized at the 2 methionine residues (positions 8 and 18), caused a loss of function. This was so far not considered in the development of PTH assays used in current clinical practice. Patients with advanced CKD are subject to oxidative stress, and plasma proteins (including PTH) are targets for oxidants. In patients with CKD, a considerable but variable fraction (about 70 to 90%) of measured PTH appears to be oxidized. Oxidized PTH (oxPTH) does not interact with the PTH receptor resulting in loss of biological activity. Currently used intact PTH (iPTH) assays detect both oxidized and non-oxPTH (n-oxPTH). Clinical studies demonstrated that bioactive, n-oxPTH, but not iPTH nor oxPTH, is associated with mortality in CKD patients.

  3. Influence of MRI field strength on clinical decision making in knee cartilage injury – A case study

    PubMed Central

    Cashman, Glenn; Attariwala, Raj

    2014-01-01

    Objective: To increase clinicians’ awareness of the differences in image resolution and potential diagnostic accuracy between small and large-field MR Scanners. To present an example of a clinical decision making challenge in how to proceed when knee MRI and clinical findings don’t agree. Clinical Features: A 38 year old female mountain biker presented with knee pain and clinical features strongly suggestive of a torn meniscus or loose bodies. An initial MRI using a small field strength (0.18T) scanner was reported as normal. Her clinical presentation was suspicious enough that a repeat MRI on a high-field (1.5T) scanner was ordered. The second MRI included high resolution 3D volumetric imaging which revealed cartilage damage and loose bodies. Intervention and Outcome: The patient was treated with arthroscopic surgery which confirmed the presence of meniscal and chondral injury and resulted in notable improvement in the patient’s symptoms. Conclusion: Clinicians should consider scanner quality and diagnostic accuracy before discounting strongly suggestive clinical history and examination findings when MRIs are reported as normal. PMID:25550664

  4. Clinical prediction model to identify vulnerable patients in ambulatory surgery: towards optimal medical decision-making.

    PubMed

    Mijderwijk, Herjan; Stolker, Robert Jan; Duivenvoorden, Hugo J; Klimek, Markus; Steyerberg, Ewout W

    2016-09-01

    Ambulatory surgery patients are at risk of adverse psychological outcomes such as anxiety, aggression, fatigue, and depression. We developed and validated a clinical prediction model to identify patients who were vulnerable to these psychological outcome parameters. We prospectively assessed 383 mixed ambulatory surgery patients for psychological vulnerability, defined as the presence of anxiety (state/trait), aggression (state/trait), fatigue, and depression seven days after surgery. Three psychological vulnerability categories were considered-i.e., none, one, or multiple poor scores, defined as a score exceeding one standard deviation above the mean for each single outcome according to normative data. The following determinants were assessed preoperatively: sociodemographic (age, sex, level of education, employment status, marital status, having children, religion, nationality), medical (heart rate and body mass index), and psychological variables (self-esteem and self-efficacy), in addition to anxiety, aggression, fatigue, and depression. A prediction model was constructed using ordinal polytomous logistic regression analysis, and bootstrapping was applied for internal validation. The ordinal c-index (ORC) quantified the discriminative ability of the model, in addition to measures for overall model performance (Nagelkerke's R (2) ). In this population, 137 (36%) patients were identified as being psychologically vulnerable after surgery for at least one of the psychological outcomes. The most parsimonious and optimal prediction model combined sociodemographic variables (level of education, having children, and nationality) with psychological variables (trait anxiety, state/trait aggression, fatigue, and depression). Model performance was promising: R (2)  = 30% and ORC = 0.76 after correction for optimism. This study identified a substantial group of vulnerable patients in ambulatory surgery. The proposed clinical prediction model could allow healthcare

  5. Robot decisions: on the importance of virtuous judgment in clinical decision making.

    PubMed

    Gelhaus, Petra

    2011-10-01

    The aim of this article is to argue for the necessity of emotional professional virtues in the understanding of good clinical practice. This understanding is required for a proper balance of capacities in medical education and further education of physicians. For this reason an ideal physician, incarnating the required virtues, skills and knowledge is compared with a non-emotional robot that is bound to moral rules. This fictive confrontation is meant to clarify why certain demands on the personality of the physician are justified, in addition to a rule- and principle-based moral orientation and biomedical knowledge and skills. Philosophical analysis of thought experiments inspired by science fiction literature by Isaac Asimov. Although prima facie a rule-oriented robot seems more reliable and trustworthy, the complexity of clinical judgment is not met by an encompassing and never contradictory set of rules from which one could logically derive decisions. There are different ways how the robot could still work, but at the cost of the predictability of its behaviour and its moral orientation. In comparison, a virtuous human doctor who is also bound to these rules, although less strictly, will more reliably keep at moral objectives, be understandable, be more flexible in case the rules come to their limits, and will be more predictable in these critical situations. Apart from these advantages of the virtuous human doctor referring to her own person, the most problematic deficit of the robot is its lacking deeper understanding of the inner mental events of patients which makes good contact, good communication and good influence impossible. Although an infallibly rule-oriented robot seems more reliable at first view, in situations that require complex decisions like clinical practice the agency of a moral human person is more trustworthy. Furthermore, the understanding of the patient's emotions must remain insufficient for a non-emotional, non-human being. Because

  6. Enhanced Visualization of Optimal Cerebral Perfusion Pressure Over Time to Support Clinical Decision Making.

    PubMed

    Aries, Marcel J H; Wesselink, Robin; Elting, Jan Willem J; Donnelly, Joseph; Czosnyka, Marek; Ercole, Ari; Maurits, Natasha M; Smielewski, Peter

    2016-10-01

    Cerebrovascular reactivity can provide a continuously updated individualized target for management of cerebral perfusion pressure, termed optimal cerebral perfusion pressure. The objective of this project was to find a way of improving the optimal cerebral perfusion pressure methodology by introducing a new visualization method. Four severe traumatic brain injury patients with intracranial pressure monitoring. Data were collected and pre-processed using ICM+ software. Sequential optimal cerebral perfusion pressure curves were used to create a color-coded maps of autoregulation - cerebral perfusion pressure relationship evolution over time. The visualization method addresses some of the main drawbacks of the original methodology and might bring the potential for its clinical application closer.

  7. A new strategy for clinical decision making: censors and neuroendocrinological diseases.

    PubMed

    Mansour, H; Molitch, M E

    1986-01-01

    A patient rarely has a single, isolated disease. The situation is usually much more complex since the different parts of the human organism and its metabolism interact with each other on multiple levels and follow several feedback patterns. These interactions and feedback patterns become even more complex when the effects of the external environment are considered. When several diseases are present, the first steps in medical diagnosis are to determine whether one of the diseases interacts with ("Censors") or changes the significant symptoms, signs, or results of the laboratory tests of the other diseases. We will try, within this paper, to go beyond the scope of the first generation of Artificial Intelligence systems in medicine to determine the effects of two diseases on each other. One important part of the effect of two diseases on each other is the effect of Censors. In addition, causal reasoning, reasoning by analogy, and learning from precedents are important and necessary for a human-like expert in medicine. Their application to thyroid diseases, with an implemented system, are considered in this paper.

  8. The use of structured reflective journal questions to promote fundamental development of clinical decision-making abilities of the first-semester nursing student.

    PubMed

    Croke, Eileen

    2004-01-01

    The ability to reflect is becoming a core competency in many nursing educational programs. A clinical journal assignment was developed for first-semester (novice) nursing students. The aim was to see if the process of reflection-on-action through the medium of journal writing promoted fundamental clinical decision-making abilities of the first semester nursing student. This author discusses components of the clinical decision-making process used to structure six clinical journal questions for use by the first semester nursing students during their clinical rotation. Exemplars of students' self-reported reflections are included.

  9. 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.

  10. Impact of Nonvascular Thoracic MR Imaging on the Clinical Decision Making of Thoracic Surgeons: A 2-year Prospective Study.

    PubMed

    Ackman, Jeanne B; Gaissert, Henning A; Lanuti, Michael; Digumarthy, Subba R; Shepard, Jo-Anne O; Halpern, Elkan F; Wright, Cameron D

    2016-08-01

    Purpose To determine the impact of nonvascular thoracic magnetic resonance (MR) imaging on the clinical decision making and diagnostic certainty of thoracic surgeons. Materials and Methods Seven thoracic surgeons at Massachusetts General Hospital, an academic quaternary referral hospital, participated in this 2-year, prospective, institution review board-approved, HIPAA-compliant pre- and post-MR imaging survey study after completing a one-time demographic survey. Between July 16, 2013, and July 13, 2015, each time a thoracic surgeon ordered a nonvascular thoracic MR imaging study via radiology order entry, he or she was sent a link to the pre-test survey that ascertained the clinical rationale for MR imaging, the clinical management plan if MR imaging was not an option, and pre-test diagnostic certainty. Upon completion of the MR imaging report, the surgeon was sent a link to the post-test survey assessing if/how MR imaging changed clinical management, the surgeon's comfort with the clinical management plan, and post-test diagnostic certainty. Data were analyzed with Student t, Wilcoxon, and McNemar tests. Results A total of 99 pre- and post-test surveys were completed. Most MR imaging studies (64 of 99 [65%]) were requested because of indeterminate computed tomographic findings. The use of MR imaging significantly reduced the number of planned surgical interventions (P < .001), modified the surgical approach in 54% (14 of 26) of surgical cases, and increased surgeon comfort with the patient management plan in 95% (94 of 99) of cases. Increased diagnostic certainty as a result of MR imaging was highly significant (P < .0001). In 21% (21 of 99) of cases, definitive MR imaging results warranted no further follow-up or clinical care. Conclusion In appropriate cases, assessment with nonvascular thoracic MR imaging substantially affects the clinical decision making and diagnostic certainty of thoracic surgeons. (©) RSNA, 2016 Online supplemental material is available

  11. 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

  12. Statistics for critical clinical decision making based on readings of pairs of implanted sensors.

    PubMed

    Schmidtke, D W; Pishko, M V; Quinn, C P; Heller, A

    1996-09-01

    Low error rates are essential if lives of patients are to depend on readings of implanted sensors, such as glucose sensors in insulin-dependent diabetic patients. To verify the operation and to calibrate on demand an implanted sensor, it is necessary that calibration through a single, independent measurement involving withdrawal of only one sample of blood and its independent analysis be feasible. Such a one-point calibration must be accurate. Borrowing from nuclear reactor safety assurance, where a likelihood ratio test is applied to readings of pairs of pressure sensors for shutdown/no shutdown decisions, we apply a similar test to sensor pairs implanted in rats. We show, for five sets of glucose sensor pairs, calibrated in vivo by withdrawal of a single sample of blood, that application of the likelihood ratio test increases the fraction of the clinically correct readings from 92.4% for their averaged readings to 98.8%.

  13. Exploring nonlinear relations: models of clinical decision making by regression with optimal scaling.

    PubMed

    Hartmann, Armin; Van Der Kooij, Anita J; Zeeck, Almut

    2009-07-01

    In explorative regression studies, linear models are often applied without questioning the linearity of the relations between the predictor variables and the dependent variable, or linear relations are taken as an approximation. In this study, the method of regression with optimal scaling transformations is demonstrated. This method does not require predefined nonlinear functions and results in easy-to-interpret transformations that will show the form of the relations. The method is illustrated using data from a German multicenter project on the indication criteria for inpatient or day clinic psychotherapy treatment. The indication criteria to include in the regression model were selected with the Lasso, which is a tool for predictor selection that overcomes the disadvantages of stepwise regression methods. The resulting prediction model indicates that treatment status is (approximately) linearly related to some criteria and nonlinearly related to others.

  14. Pharmacogenetics Informed Decision Making in Adolescent Psychiatric Treatment: A Clinical Case Report

    PubMed Central

    Smith, Teri; Sharp, Susan; Manzardo, Ann M.; Butler, Merlin G.

    2015-01-01

    Advances made in genetic testing and tools applied to pharmacogenetics are increasingly being used to inform clinicians in fields such as oncology, hematology, diabetes (endocrinology), cardiology and expanding into psychiatry by examining the influences of genetics on drug efficacy and metabolism. We present a clinical case example of an adolescent male with anxiety, attention deficit hyperactivity disorder (ADHD) and autism spectrum disorder who did not tolerate numerous medications and dosages over several years in attempts to manage his symptoms. Pharmacogenetics testing was performed and DNA results on this individual elucidated the potential pitfalls in medication use because of specific pharmacodynamic and pharmacokinetic differences specifically involving polymorphisms of genes in the cytochrome p450 enzyme system. Future studies and reports are needed to further illustrate and determine the type of individualized medicine approach required to treat individuals based on their specific gene patterns. Growing evidence supports this biological approach for standard of care in psychiatry. PMID:25710722

  15. [Diagnosis and clinical decision making: a conceptional framework for predictive pathology].

    PubMed

    Lorenz, W; Koller, M; Ehret, C; Klinkhammer-Schalke, M

    2006-01-01

    In the clinical pathway of diagnosis and therapy of diseases two decisions are distinguished: diagnostic and therapeutic decision. The former is analysed by decision tables, the latter by decision trees. In both decisions pathology plays a dominant role, especially as a gold standard that is a test to which most people have developed trust. This definition is remarkably soft. An efficient diagnostic prediction depends on a high prevalence of the disease. This is frequently forgotten when tests have a high sensitivity and specificity. The mathematical concept behind this observation is the Bayesian theorem. This is highly important for predictive pathology because it allows to combine attributes with high likelihood ratio simply by multiplication and has been shown to be remarkably stable, e. g. in the differential diagnosis of acute abdominal pain. Pathology should take the leadership in prediction since it has a considerable power as the gold standard of many tests. However, a network is advisable with other basic disciplines.

  16. The problem-oriented system, problem-knowledge coupling, and clinical decision making.

    PubMed

    Weed, L L; Zimny, N J

    1989-07-01

    The information tool to aid us in making the clinical decisions discussed in this presentation is called the PKC. Our goal with patients should be to couple the knowledge of the unique patient to the knowledge in the literature and get the best possible match. This approach requires combinatorial versus probabilistic thinking. In the real world, ideal matches are not found. Therefore, it is critical to exhaust the patient's uniqueness first and only then use probabilities to settle further uncertainties. It is an error to teach people how to deal with uncertainty instead of teaching them to clean up a great deal of the uncertainty first. Patients must be involved in this endeavor. In essence, they have a PhD in their own uniqueness, and it is this uniqueness that is very powerful in solving complex problems. This method of patient evaluation and management cannot be used with the unaided mind. It requires new and powerful information tools like the PKC. All information that is relevant to a problem should be included in the coupler. It should encompass differing points of view, and the rationale should be made explicit to clinician and patient alike. When complete, the coupler should represent an interdisciplinary compilation of questions and tests that are expected to be collected every time in the clinic for the type of problem the coupler represents. This method will provide a basis for quality control because the contents of the coupler now have defined what we expect to occur in every patient encounter.(ABSTRACT TRUNCATED AT 250 WORDS)

  17. Clinical decision making by dentists working in the NHS General Dental Services since April 2006.

    PubMed

    Davies, B J B; Macfarlane, F

    2010-11-27

    In April 2006 a new contract was introduced that governed how NHS General Dental Practitioners would be funded for the services they provide. This study looks at the impact that the contract has had in the three years since its introduction, evaluating its influence on the clinical care that patients receive and the clinical decisions that dentists are making. This qualitative service evaluation involved interviewing 12 dentists representative of a range of NHS dentists involved with the new NHS dental contract using a semi-structured approach. We found evidence that the new contract has led to dentists making different decisions in their daily practice and sometimes altering their treatment plans and referral patterns to ensure that their business is not disadvantaged. Access to care for some patients without a regular dentist can be compromised by the new contract as it can be financially challenging for a dentist to accept to care for a new patient who has an unknown and potentially large need for treatment. Cherry-picking of potentially more profitable patients may be common. The incentive is to watch borderline problems rather than to treat if a treatment band threshold has already been crossed and treatment may be delayed until a later course of treatment for the same reason. Dentists often feel that complex treatments (for example, endodontic treatments) are financially unviable. Some dentists are referring difficult cases that might previously have been treated 'in house', such as extractions, to another provider, as this enables offloading of costs while potentially retaining full fees. Younger and less experienced dentists may be further pressured.

  18. From Value Assessment to Value Cocreation: Informing Clinical Decision-Making with Medical Claims Data.

    PubMed

    Thompson, Steven; Varvel, Stephen; Sasinowski, Maciek; Burke, James P

    2016-09-01

    Big data and advances in analytical processes represent an opportunity for the healthcare industry to make better evidence-based decisions on the value generated by various tests, procedures, and interventions. Value-based reimbursement is the process of identifying and compensating healthcare providers based on whether their services improve quality of care without increasing cost of care or maintain quality of care while decreasing costs. In this article, we motivate and illustrate the potential opportunities for payers and providers to collaborate and evaluate the clinical and economic efficacy of different healthcare services. We conduct a case study of a firm that offers advanced biomarker and disease state management services for cardiovascular and cardiometabolic conditions. A value-based analysis that comprised a retrospective case/control cohort design was conducted, and claims data for over 7000 subjects who received these services were compared to a matched control cohort. Study subjects were commercial and Medicare Advantage enrollees with evidence of CHD, diabetes, or a related condition. Analysis of medical claims data showed a lower proportion of patients who received biomarker testing and disease state management services experienced a MI (p < 0.01) or diabetic complications (p < 0.001). No significant increase in cost of care was found between the two cohorts. Our results illustrate the opportunity healthcare payers such as Medicare and commercial insurance companies have in terms of identifying value-creating healthcare interventions. However, payers and providers also need to pursue system integration efforts to further automate the identification and dissemination of clinically and economically efficacious treatment plans to ensure at-risk patients receive the treatments and interventions that will benefit them the most.

  19. Artificial intelligence framework for simulating clinical decision-making: a Markov decision process approach.

    PubMed

    Bennett, Casey C; Hauser, Kris

    2013-01-01

    In the modern healthcare system, rapidly expanding costs/complexity, the growing myriad of treatment options, and exploding information streams that often do not effectively reach the front lines hinder the ability to choose optimal treatment decisions over time. The goal in this paper is to develop a general purpose (non-disease-specific) computational/artificial intelligence (AI) framework to address these challenges. This framework serves two potential functions: (1) a simulation environment for exploring various healthcare policies, payment methodologies, etc., and (2) the basis for clinical artificial intelligence - an AI that can "think like a doctor". This approach combines Markov decision processes and dynamic decision networks to learn from clinical data and develop complex plans via simulation of alternative sequential decision paths while capturing the sometimes conflicting, sometimes synergistic interactions of various components in the healthcare system. It can operate in partially observable environments (in the case of missing observations or data) by maintaining belief states about patient health status and functions as an online agent that plans and re-plans as actions are performed and new observations are obtained. This framework was evaluated using real patient data from an electronic health record. The results demonstrate the feasibility of this approach; such an AI framework easily outperforms the current treatment-as-usual (TAU) case-rate/fee-for-service models of healthcare. The cost per unit of outcome change (CPUC) was $189 vs. $497 for AI vs. TAU (where lower is considered optimal) - while at the same time the AI approach could obtain a 30-35% increase in patient outcomes. Tweaking certain AI model parameters could further enhance this advantage, obtaining approximately 50% more improvement (outcome change) for roughly half the costs. Given careful design and problem formulation, an AI simulation framework can approximate optimal

  20. Ability of online drug databases to assist in clinical decision-making with infectious disease therapies.

    PubMed

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

    2008-11-06

    Infectious disease (ID) is a dynamic field with new guidelines being adopted at a rapid rate. Clinical decision support tools (CDSTs) have proven beneficial in selecting treatment options to improve outcomes. However, there is a dearth of information on the abilities of CDSTs, such as drug information databases. This study evaluated online drug information databases when answering infectious disease-specific queries. Eight subscription drug information databases: American Hospital Formulary Service Drug Information (AHFS), Clinical Pharmacology (CP), Epocrates Online Premium (EOP), Facts & Comparisons 4.0 Online (FC), Lexi-Comp (LC), Lexi-Comp with AHFS (LC-AHFS), Micromedex (MM), and PEPID PDC (PPDC) and six freely accessible: DailyMed (DM), DIOne (DIO), Epocrates Online Free (EOF), Internet Drug Index (IDI), Johns Hopkins ABX Guide (JHAG), and Medscape Drug Reference (MDR) were evaluated for their scope (presence of an answer) and completeness (on a 3-point scale) in answering 147 infectious disease-specific questions. Questions were divided among five classifications: antibacterial, antiviral, antifungal, antiparasitic, and vaccination/immunization. Classifications were further divided into categories (e.g., dosage, administration, emerging resistance, synergy, and spectrum of activity). Databases were ranked based on scope and completeness scores. ANOVA and Chi-square were used to determine differences between individual databases and between subscription and free databases. Scope scores revealed three discrete tiers of database performance: Tier 1 (82-77%), Tier 2 (73-65%) and Tier 3 (56-41%) which were significantly different from each other (p < 0.05). The top tier performers: MM (82%), MDR (81%), LC-AHFS (81%), AHFS (78%), and CP (77%) answered significantly more questions compared to other databases (p < 0.05). Top databases for completeness were: MM (97%), DM (96%), IDI (95%), and MDR (95%). Subscription databases performed better than free databases in

  1. Ability of online drug databases to assist in clinical decision-making with infectious disease therapies

    PubMed Central

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

    2008-01-01

    Background Infectious disease (ID) is a dynamic field with new guidelines being adopted at a rapid rate. Clinical decision support tools (CDSTs) have proven beneficial in selecting treatment options to improve outcomes. However, there is a dearth of information on the abilities of CDSTs, such as drug information databases. This study evaluated online drug information databases when answering infectious disease-specific queries. Methods Eight subscription drug information databases: American Hospital Formulary Service Drug Information (AHFS), Clinical Pharmacology (CP), Epocrates Online Premium (EOP), Facts & Comparisons 4.0 Online (FC), Lexi-Comp (LC), Lexi-Comp with AHFS (LC-AHFS), Micromedex (MM), and PEPID PDC (PPDC) and six freely accessible: DailyMed (DM), DIOne (DIO), Epocrates Online Free (EOF), Internet Drug Index (IDI), Johns Hopkins ABX Guide (JHAG), and Medscape Drug Reference (MDR) were evaluated for their scope (presence of an answer) and completeness (on a 3-point scale) in answering 147 infectious disease-specific questions. Questions were divided among five classifications: antibacterial, antiviral, antifungal, antiparasitic, and vaccination/immunization. Classifications were further divided into categories (e.g., dosage, administration, emerging resistance, synergy, and spectrum of activity). Databases were ranked based on scope and completeness scores. ANOVA and Chi-square were used to determine differences between individual databases and between subscription and free databases. Results Scope scores revealed three discrete tiers of database performance: Tier 1 (82-77%), Tier 2 (73-65%) and Tier 3 (56-41%) which were significantly different from each other (p < 0.05). The top tier performers: MM (82%), MDR (81%), LC-AHFS (81%), AHFS (78%), and CP (77%) answered significantly more questions compared to other databases (p < 0.05). Top databases for completeness were: MM (97%), DM (96%), IDI (95%), and MDR (95%). Subscription databases performed

  2. Comprehension of Randomization and Uncertainty in Cancer Clinical Trials Decision-Making among Rural, Appalachian Patients

    PubMed Central

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

    2015-01-01

    Objective Comprehension of randomization is a vital, but understudied, component of informed consent to participate in cancer randomized clinical trials (RCTs). This study examines patient comprehension of the randomization process as well as sources of ongoing uncertainty that may inhibit a patient's ability to provide informed consent to participate in RCTs. Methods Cancer patients living in rural Appalachia who were offered an opportunity to participate in cancer treatment RCT completed in-depth interviews and a brief survey. Results No systematic differences in randomization comprehension between patients who consented and those who declined participation in a cancer RCT were detected. Comprehension is conceptually distinct from uncertainty, with patients who had both high and low comprehension experiencing randomization-related uncertainty. Uncertainty about randomization was found to have cognitive and affective dimensions. Conclusion Not all patients enrolling in RCTs have sufficient understanding of the randomization process to provide informed consent. Healthcare providers need to be aware of the different types of randomization-related uncertainty. Efforts to improve informed consent to participate in RCTs should focus on having patients “teach back” their understanding of randomization. This practice could yield valuable information about the patient's cognitive and affective understanding of randomization as well as opportunities to correct misperceptions. Education about RCTs should reflect patient expectations of individualized care by explaining how all treatments being compared are appropriate to the specifics of a patient's disease. PMID:25608719

  3. Comprehension of Randomization and Uncertainty in Cancer Clinical Trials Decision Making Among Rural, Appalachian Patients.

    PubMed

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

    2015-12-01

    Comprehension of randomization is a vital, but understudied, component of informed consent to participate in cancer randomized clinical trials (RCTs). This study examines patient comprehension of the randomization process as well as sources of ongoing uncertainty that may inhibit a patient's ability to provide informed consent to participate in RCTs. Cancer patients living in rural Appalachia who were offered an opportunity to participate in a cancer treatment RCT completed in-depth interviews and a brief survey. No systematic differences in randomization comprehension between patients who consented and those who declined participation in a cancer RCT were detected. Comprehension is conceptually distinct from uncertainty, with patients who had both high and low comprehension experiencing randomization-related uncertainty. Uncertainty about randomization was found to have cognitive and affective dimensions. Not all patients enrolling in RCTs have a sufficient understanding of the randomization process to provide informed consent. Healthcare providers need to be aware of the different types of randomization-related uncertainty. Efforts to improve informed consent to participate in RCTs should focus on having patients teach back their understanding of randomization. This practice could yield valuable information about the patient's cognitive and affective understanding of randomization as well as opportunities to correct misperceptions. Education about RCTs should reflect patient expectations of individualized care by explaining how all treatments being compared are appropriate to the specifics of a patient's disease.

  4. Predisposing risk factors on susceptibility to exertional heat illness: clinical decision-making considerations.

    PubMed

    Cleary, Michelle

    2007-08-01

    To present strategies for identifying predisposing conditions, susceptibility, and incidence reduction for the most common exertional heat illnesses (EHI): heat cramps, heat exhaustion, and most importantly, heat stroke. A comprehensive literature review of MEDLINE and 1996 to 2006, including all retrospective, controlled studies of EHI risk using the following keywords: exertional heat illness risk, exertional heat stroke risk, and exercise-induced dehydration risk. Search limits included the following: English language, published in the last 10 years, clinical trial, meta-analysis, practice guideline, randomized controlled trial, review, and humans. A manual review was conducted of relevant position statements and book chapters including the reference lists. To evaluate the quality of the empirical studies to be included in this review, each study must have scored at least 17/22 or 77% of items included when reporting a randomized trial using the CONSORT checklist. Many cases of EHI are preventable and can be successfully treated if the ATC identifies individuals at increased relative risk and implement appropriate prevention strategies. The ability to objectively identify individuals at increased relative risk of EHI and to provide appropriate monitoring is critical in EHI prevention and reduction of repeated incidents of EHI. For any heat illness prevention program to be effective, greater attention and continued observation is needed for athletes at high risk for EHI. For many athletic teams or programs, because of the sheer numbers and associated catastrophic injury potential, health care professionals must implement a system by which high-risk individuals are monitored during activity with the highest level of vigilance for prevention of EHI.

  5. The Effect of Level of Patient Acuity, Critical Care Experience, and ACLS Certification on Clinical Decision Making: Implications for Computer Decision Support Systems

    PubMed Central

    Henry, Suzanne Bakken

    1990-01-01

    This study examined the effect of patient acuity, critical care experience, and ACLS certification on clinical decision making. Each subject (N=68) completed two computerized clinical simulations. Ventricular tachycardia (VT) represented the high acuity situation and atrial flutter (AF) the lower acuity situation. Clinical decision making was measured by proficiency score, patient outcome (cure/die), and amount of data collected. In the AF simulation, proficiency scores were higher (p=.000), more dysrhythmias were cured (p<.005), and more data were collected (p=.040) than in the VT simulation. Experienced and inexperienced nurses did not differ on proficiency score, however, inexperienced nurses collected more data (p=.048) and cured fewer atrial flutter simulations (p=.04). ACLS certified nurses had higher proficiency scores (p=.033) and collected less data (p=.048). Clinical decision making on two simulations was affected by patient acuity, critical care experience, and ACLS certification. These findings have implications for the design and implementation of clinical decision support systems.

  6. Interorganizational decision making.

    NASA Technical Reports Server (NTRS)

    Tuite, M. (Editor); Chisholm, R.; Radnor, M.

    1972-01-01

    The papers are both theoretical and applied. They include contributions from a spectrum of academic specializations and from practitioners representing several organizations. The papers are divided into theoretical and applied groupings reflecting a variety of systems levels and institutional examples, and into those papers which emphasized the organization structure requirements of interorganizational decision making, those that emphasized the behavioral requirements of interorganizational decision making, and those that developed decision technologies for interorganizational decision making.

  7. Integrated case studies and medical decision making: a novel, computer-assisted bridge from the basic sciences to the clinics.

    PubMed

    Schor, N F; Troen, P; Adler, S; Williams, J G; Kanter, S L; Mahling, D E; Sorrows, B; Skogseid, I; Bernier, G M

    1995-09-01

    This article describes a novel course that was designed to bridge the gap between the basic science years and clinical experiences in medical school by using information science and computer technology as major components of problem-based learning (PBL) sessions. The course, Integrated Case Studies and Medical Decision Making, was first given to second-year students at the University of Pittsburgh School of Medicine in the spring of 1994. It consists of 13 PBL exercises, each of which explores a clinical case. The cases, including images and gated access to information, are housed on a computer. Using one of 16 networked terminals in specially designed small-group rooms, groups of nine students progress through the cases with a faculty facilitator. The responses of students and faculty to the initial year of the course were favorable. In comparison with traditional PBL sessions, enhanced quality of and access to images and accountability for accessing case information in sequential fashion were cited as major strengths of the course. Juxtaposition of basic science and clinical material and utility in reviewing for the United States Medical Licensing Examination were also cited as strengths. The diversity of the basic science material involved in completing the cases drew overwhelming enthusiasm from students and facilitators alike. In conclusion, the course successfully employs computer and information science technology, which will be of increasing importance to future physicians. The course also serves as an effective bridge to the clinical years of medical school and as a study adjunct for the USMLE.

  8. Interpretation of Renal Quality of Life Profile scores in routine clinical practice: an aid to treatment decision-making.

    PubMed

    Aawar, Nadine; Moore, Richard; Riley, Stephen; Salek, Sam

    2016-07-01

    High Renal Quality of Life Profile (RQLP) scores are associated with impaired health-related quality of life; however, the clinical meaning of the scores is difficult for clinicians and healthcare planners to interpret. The aim of this study was to determine clinical significance of RQLP scores which could be used to aid clinical decision-making. The anchor-based technique (a method for categorizing numeric scores to ease interpretation) was used to develop a categorization system for the RQLP scores using a global question (GQ). The GQ scores (i.e. no effect to extremely large effect) were mapped against the RQLP scores, and intraclass correlation coefficient (ICC) was used to test their agreement. The RQLP and the GQ were administered to 260 adult patients (males = 165 and females = 95) with chronic renal failure (CRF). The mean RQLP score was 67.2, median = 61, SD = 41.5, and range 0-172. The mean GQ score was 1.74, median = 2, SD = 1.27, and range 0-4. The mean, mode, and median of the GQ scores for each RQLP score were used to devise several sets of categories of RQLP score, and the ICC test of agreement was calculated. The proposed set of RQLP score banding for adoption includes: 0-20 = no effect on patient's life (GQ = 0, n = 35); 21-51 = small effect on patient's life (GQ = 1, n = 66); 52-93 = moderate effect on patient's life (GQ = 2, n = 87); 94-134 = very large effect on patient's life (GQ = 3, n = 54); and 135-172 = extremely large effect on patient's life (GQ = 4, n = 18). The ICC coefficient for the proposed banding system was 0.80. The proposed categorization of the RQLP will aid the clinical interpretation of change in RQLP score informing treatment decision-making in routine practice.

  9. Developing a physiotherapy-specific preliminary clinical decision-making tool for oxygen titration: a modified delphi study.

    PubMed

    Duong, Michelle; Bertin, Kendra; Henry, Renee; Singh, Deepti; Timmins, Nolla; Brooks, Dina; Mathur, Sunita; Ellerton, Cindy

    2014-01-01

    To develop and evaluate a preliminary clinical decision-making tool (CDMT) to assist physiotherapists in titrating oxygen for acutely ill adults in Ontario. A panel of 14 experienced cardiorespiratory physiotherapists was recruited. Factors relating to oxygen titration were identified using a modified Delphi technique. Four rounds of questionnaires were conducted, during which the goals were to (1) generate factors, (2) reduce factors and debate contentious factors, (3) finalize factors and develop the preliminary CDMT, and (4) evaluate the usability of the tool in a clinical context. The panel reached consensus on a total of 89 factors, which were compiled to create the preliminary CDMT. The global tool reached consensus for sensibility, receiving a mean score of 6/7 on a 7-point Likert-type scale (1=unacceptable; 7=excellent). Five of the nine individual components of evaluation of the tool achieved scores ≥6.0; the remaining four had mean scores between 5.4 and 5.9. This study produced a preliminary CDMT for oxygen titration, which the panel agreed was highly comprehensible and globally sensible. Further research is necessary to evaluate the sensibility and applicability of the tool in a clinical setting.

  10. Genomic Profiling of Thyroid Nodules: Current Role for ThyroSeq Next-Generation Sequencing on Clinical Decision-Making

    PubMed Central

    Kargi, Atil Y.; Bustamante, Marcela Perez; Gulec, Seza

    2017-01-01

    In recent years there has been an increased awareness of the genetic alterations underlying both benign and malignant neoplasms of the thyroid. Next-generation sequencing (NGS) is an emerging technology that allows for rapid detection of a large number of genetic mutations in thyroid fine-needle aspiration (FNA) specimens. NGS for targeted mutational analysis in thyroid tumors has been proposed as a tool to assist in the diagnosis of thyroid nodules with indeterminate FNA cytology. Results of genomic testing of thyroid nodules and thyroid cancers could also have prognostic implications and play a role in determining optimal treatment strategies including targeted therapies. We provide a critical review of existing studies assessing the performance of the ThyroSeq NGS test for the diagnosis and management of patients with thyroid nodules with indeterminate cytopathology and discuss the applicability of findings from these studies to clinical practice. While there are early indications to suggest a possible utility of data obtained from NGS to aid in prognostication and therapeutic decision-making in thyroid cancer, we recommend judicious use and cautious interpretation of such molecular testing until results of ongoing clinical trials become available. Lastly, we discuss recommendations provided from clinical practice guidelines regarding the use of mutation detection via NGS in the diagnostic evaluation of thyroid nodules. PMID:28117287

  11. Validity evidence for Surgical Improvement of Clinical Knowledge Ops: a novel gaming platform to assess surgical decision making.

    PubMed

    Lin, Dana T; Park, Julia; Liebert, Cara A; Lau, James N

    2015-01-01

    Current surgical education curricula focus mainly on the acquisition of technical skill rather than clinical and operative judgment. SICKO (Surgical Improvement of Clinical Knowledge Ops) is a novel gaming platform developed to address this critical need. A pilot study was performed to collect validity evidence for SICKO as an assessment for surgical decision making. Forty-nine subjects stratified into 4 levels of expertise were recruited to play SICKO. Later, players were surveyed regarding the realism of the gaming platform as well as the clinical competencies required of them while playing SICKO. Each group of increasing expertise outperformed the less experienced groups. Mean total game scores for the novice, junior resident, senior resident, and expert groups were 5,461, 8,519, 11,404, and 13,913, respectively (P = .001). Survey results revealed high scores for realism and content. SICKO holds the potential to be not only an engaging and immersive educational tool, but also a valid assessment in the armamentarium of surgical educators. Published by Elsevier Inc.

  12. Developing a Physiotherapy-Specific Preliminary Clinical Decision-Making Tool for Oxygen Titration: A Modified Delphi Study

    PubMed Central

    Duong, Michelle; Bertin, Kendra; Henry, Renee; Singh, Deepti; Timmins, Nolla; Brooks, Dina; Mathur, Sunita

    2014-01-01

    ABSTRACT Purpose: To develop and evaluate a preliminary clinical decision-making tool (CDMT) to assist physiotherapists in titrating oxygen for acutely ill adults in Ontario. Methods: A panel of 14 experienced cardiorespiratory physiotherapists was recruited. Factors relating to oxygen titration were identified using a modified Delphi technique. Four rounds of questionnaires were conducted, during which the goals were to (1) generate factors, (2) reduce factors and debate contentious factors, (3) finalize factors and develop the preliminary CDMT, and (4) evaluate the usability of the tool in a clinical context. Results: The panel reached consensus on a total of 89 factors, which were compiled to create the preliminary CDMT. The global tool reached consensus for sensibility, receiving a mean score of 6/7 on a 7-point Likert-type scale (1=unacceptable; 7=excellent). Five of the nine individual components of evaluation of the tool achieved scores ≥6.0; the remaining four had mean scores between 5.4 and 5.9. Conclusion: This study produced a preliminary CDMT for oxygen titration, which the panel agreed was highly comprehensible and globally sensible. Further research is necessary to evaluate the sensibility and applicability of the tool in a clinical setting. PMID:25125782

  13. 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

  14. Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial: A survival prediction model to facilitate clinical decision making.

    PubMed

    Bradbury, Andrew W; Adam, Donald J; Bell, Jocelyn; Forbes, John F; Fowkes, F Gerry R; Gillespie, Ian; Ruckley, Charles Vaughan; Raab, Gillian M

    2010-05-01

    An intention-to-treat analysis of the Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial showed that in patients with severe lower limb ischemia (SLI) due to infrainguinal disease who survived for 2 years after intervention, initial randomization to a bypass surgery (BSX)-first vs balloon angioplasty (BAP)-first revascularization strategy was associated with improvements in subsequent overall survival (OS) and amputation-free survival (AFS) of about 7 and 6 months, respectively. This study explored the value of baseline factors to estimate the likelihood of survival to 2 years for the trial cohort (Cox model) and for individual BASIL trial patients (Weibull model) as an aid to clinical decision making. Of 452 patients presenting to 27 United Kingdom hospitals, 228 were randomly assigned to a BSX-first and 224 to a BAP-first revascularization strategy. Patients were monitored for at least 3 years. Baseline factors affecting the survival of the entire cohort were examined with a multivariate Cox model. The chances of survival at 1 and 2 years for patients with given baseline characteristics were estimated with a Weibull parametric model. At the end of follow-up, 172 patients (38%) were alive without major limb amputation of the trial leg, and 202 (45%) were alive. Baseline factors that were significant in the Cox model were BASIL randomization stratification group, below knee Bollinger angiogram score, body mass index, age, diabetes, creatinine level, and smoking status. Using these factors to define five equally sized groups, we identified patients with 2-year survival rates of 50% to 90%. The factors that contributed to the Weibull predictive model were age, presence of tissue loss, serum creatinine, number of ankle pressure measurements detectable, maximum ankle pressure measured, a history of myocardial infarction or angina, a history of stroke or transient ischemia attack, below knee Bollinger angiogram score, body mass index, and smoking

  15. Numeracy and Medicare Part D: the importance of choice and literacy for numbers in optimizing decision making for Medicare's prescription drug program.

    PubMed

    Wood, Stacey; Hanoch, Yaniv; Barnes, Andrew; Liu, Pi-Ju; Cummings, Janet; Bhattacharya, Chandrima; Rice, Thomas

    2011-06-01

    Studies on decision making have come to challenge the idea that having more choice is necessarily better. The Medicare prescription drug program (Part D) has been designed to maximize choice for the consumer but has simultaneously created a highly complex decision task with dozens of options. In this study, in a sample of 121 adults, we examined the impact that increasing choice options has on decision-making abilities in older versus younger adults. Consistent with our hypotheses, we found that participants performed better with less choice versus more choice, and that older adults performed worse than younger adults across conditions. We further examined the role that numeracy may play in making these decisions and the role of more traditional cognitive variables such as working memory, executive functioning, intelligence, and education. Finally, we examined how personality style may interact with cognitive variables and age in decision making. Regression analysis revealed that numeracy is related to performance across the lifespan. When controlling for additional measures of cognitive ability, we found that although age was no longer associated with performance, numeracy remained significant. In terms of decision style, personality characteristics were not related to performance. Our results add to the mounting evidence for the critical role of numeracy in decision making across decision domains and across the lifespan.

  16. Improving Decision Making.

    ERIC Educational Resources Information Center

    Mehallis, Mantha, Ed.

    1981-01-01

    This collection of essays focuses on the importance of accurate and timely information for effective decision making. First, Ivan Lach considers the proliferation of statewide planning and policy formation and discusses problems with and ways to improve statewide research. Next, Cheryl Opacinch focuses on decision making for federal postsecondary…

  17. 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.

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

    PubMed Central

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

    2014-01-01

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

  19. Genotype, Clinical Course, and Therapeutic Decision Making in 76 Infants with Severe Generalized Junctional Epidermolysis Bullosa.

    PubMed

    Hammersen, Johanna; Has, Cristina; Naumann-Bartsch, Nora; Stachel, Daniel; Kiritsi, Dimitra; Söder, Stephan; Tardieu, Mathilde; Metzler, Markus; Bruckner-Tuderman, Leena; Schneider, Holm

    2016-11-01

    Severe generalized junctional epidermolysis bullosa, a lethal hereditary blistering disorder, is usually treated by palliative care. Allogeneic stem cell transplantation (SCT) has been proposed as a therapeutic approach, yet without clinical evidence. Decision making was evaluated retrospectively in 76 patients with severe generalized junctional epidermolysis bullosa born in the years 2000-2015. The diagnosis was based on the absence of laminin-332 in skin biopsies. With an incidence of 1 of 150,000, severe generalized junctional epidermolysis bullosa occurred more often than published previously. Eleven as yet unreported mutations in the laminin-332 genes were detected. Although patients homozygous for the LAMB3 mutation c.1903C>T lived longer than the others, life expectancy was greatly diminished (10.8 vs. 4.6 months). Most patients failed to thrive. In two patients with initially normal weight gain, the decision for SCT from haploidentical bone marrow or peripheral blood was made. Despite transiently increasing skin erosions, the clinical status of both subjects stabilized for several weeks after SCT, but finally deteriorated. Graft cells, but no laminin-332, were detected in skin biopsies. The patients died 96 and 129 days after SCT, respectively, one of them after receiving additional skin grafts. Treatment of severe generalized junctional epidermolysis bullosa by SCT is a last-ditch attempt still lacking proof of efficacy. Copyright © 2016 The Authors. Published by Elsevier Inc. All rights reserved.

  20. Clinical decision making in a high-risk primary care environment: a qualitative study in the UK.

    PubMed

    Balla, John; Heneghan, Carl; Thompson, Matthew; Balla, Margaret

    2012-01-01

    Examine clinical reasoning and decision making in an out of hours (OOH) primary care setting to gain insights into how general practitioners (GPs) make clinical decisions and manage risk in this environment. Semi-structured interviews using open-ended questions. A 2-month qualitative interview study conducted in Oxfordshire, UK. 21 GPs working in OOH primary care. The most powerful themes to emerge related to dealing with urgent potentially high-risk cases, keeping patients safe and responding to their needs, while trying to keep patients out of hospital and the concept of 'fire fighting'. There were a number of well-defined characteristics that GPs reported making presentations easy or difficult to deal with. Severely ill patients were straightforward, while the older people, with complex multisystem diseases, were often difficult. GPs stopped collecting clinical information and came to clinical decisions when high-risk disease and severe illness requiring hospital attention has been excluded; they had responded directly to the patient's needs and there was a reliable safety net in place. Learning points that GPs identified as important for trainees in the OOH setting included the importance of developing rapport in spite of time pressures, learning to deal with uncertainty and learning about common presentations with a focus on critical cues to exclude severe illness. The findings support suggestions that improvements in primary care OOH could be achieved by including automated and regular timely feedback system for GPs and individual peer and expert clinician support for GPs with regular meetings to discuss recent cases. In addition, trainee support and mentoring to focus on clinical skills, knowledge and risk management issues specific to OOH is currently required. Investigating the stopping rules used for diagnostic closure may provide new insights into the root causes of clinical error in such a high-risk setting.

  1. Development and testing of study tools and methods to examine ethnic bias and clinical decision-making among medical students in New Zealand: The Bias and Decision-Making in Medicine (BDMM) study.

    PubMed

    Harris, Ricci; Cormack, Donna; Curtis, Elana; Jones, Rhys; Stanley, James; Lacey, Cameron

    2016-07-11

    Health provider racial/ethnic bias and its relationship to clinical decision-making is an emerging area of research focus in understanding and addressing ethnic health inequities. Examining potential racial/ethnic bias among medical students may provide important information to inform medical education and training. This paper describes the development, pretesting and piloting of study content, tools and processes for an online study of racial/ethnic bias (comparing Māori and New Zealand European) and clinical decision-making among final year medical students in New Zealand (NZ). The study was developed, pretested and piloted using a staged process (eight stages within five phases). Phase 1 included three stages: 1) scoping and conceptual framework development; 2) literature review and identification of potential measures and items; and, 3) development and adaptation of study content. Three main components were identified to assess different aspects of racial/ethnic bias: (1) implicit racial/ethnic bias using NZ-specific Implicit Association Tests (IATs); (2) explicit racial/ethnic bias using direct questions; and, (3) clinical decision-making, using chronic disease vignettes. Phase 2 (stage 4) comprised expert review and refinement. Formal pretesting (Phase 3) included construct testing using sorting and rating tasks (stage 5) and cognitive interviewing (stage 6). Phase 4 (stage 7) involved content revision and building of the web-based study, followed by pilot testing in Phase 5 (stage 8). Materials identified for potential inclusion performed well in construct testing among six participants. This assisted in the prioritisation and selection of measures that worked best in the New Zealand context and aligned with constructs of interest. Findings from the cognitive interviewing (nine participants) on the clarity, meaning, and acceptability of measures led to changes in the final wording of items and ordering of questions. Piloting (18 participants) confirmed the

  2. The evaluation of a continuing professional development package for primary care dentists designed to reduce stress, build resilience and improve clinical decision-making.

    PubMed

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

    2017-08-25

    Introduction Stress and burnout are widely accepted as a problem for primary care dental practitioners. Previous programmes to address this issue have met with some success. Burnout is associated with poor coping skills and emotion regulation, and increased rates of clinical errors. Anxiety is associated with poor decision-making and is thought to be associated with poor clinical decision-making. Attempts to improve decision-making use increasing meta-awareness and review of thinking processes. Bibliotherapy is an effective method of delivering cognitive behavioural therapy as self-help or guided self-help (with some therapist input) formats.Objective To evaluate the efficacy of a specially designed CPD package which was designed to improve coping skills, build resilience and reduce the impact of anxiety on dentists' clinical decision-making.Design A multi-centred quasi-experiment.Setting Lincolnshire and Nottinghamshire (England) 2014.Materials and methods Thirty-five volunteer primary care dentists used two versions (self-help [SH] and guided self-help [GSH], which included a 3 hour workshop) of a specially written cognitive behavioural therapy bibliotherapy programme designed to improve well-being and decision-making.Main Outcome Measures The main outcome measures were dentists' burnout, depression, anxiety, stress and decision-making style. Data were also collected on use and evaluation of the programme.Results At 6 weeks there was a clinically and statistically significant reduction in depression, anxiety and stress levels, a statistically significant reduction in burnout (emotional exhaustion) and hypervigilant decision-making, and an increase in personal achievement. The improvements in depression, stress, emotional exhaustion and hypervigilant decision-making were maintained at 6 months. Dentists were overwhelmingly positive in their evaluation of the project and used most of its contents.Conclusion With the caveat of small numbers and the lack of a no

  3. Taking back your turf: understanding the role of law in medical decision making in opioid management (Part II--putting legal/regulatory materials to work for you).

    PubMed

    Bolen, Jennifer

    2005-01-01

    In Part I of this series, I discussed the basic role of the law in the decision-making process for opioid management. I set out three basic rules: 1) read and learn applicable federal and state legal/regulatory materials on using controlled substances to treat pain, 2) stay current on accepted clinical standards of care, and 3) use a compliance program to minimize the potential for abuse and diversion of controlled substances. Here in Part II, I focus on the third rule and offer a few suggestions on developing and maintaining a compliance program. I also discuss using language from legal/regulatory materials in your practice forms in a manner that, once again, allows you to "take back your turf" and prescribe opioids without fear of legal/regulatory sanction (see Disclaimer). Take a minute to review the self-audit questions that follow and see where you stand on your knowledge and use of legal/regulatory matters in your daily practice. More "yes" answers indicate better knowledge of key compliance and documentation issues. More "no" and "I don't know" answers indicate that more work should be done to minimize potential legal/regulatory compliance problems in your practice.

  4. New Sepsis Definition (Sepsis-3) and Community-acquired Pneumonia Mortality: A Validation and Clinical Decision-making Study.

    PubMed

    Ranzani, Otavio T; Prina, Elena; Menéndez, Rosario; Ceccato, Adrian; Cilloniz, Catia; Méndez, Raul; Gabarrus, Albert; Barbeta, Enric; Li Bassi, Gianluigi; Ferrer, Miquel; Torres, Antoni

    2017-06-14

    Sepsis-3 Task Force updated the clinical criteria for sepsis, excluding the need for systemic inflammatory response syndrome (SIRS) criteria. The clinical implications of the proposed flowchart including the quick Sequential (Sepsis-related) Organ Failure Assessment (qSOFA) and SOFA scores are unknown. To perform a clinical decision-making analysis of Sepsis-3 in patients with community-acquired pneumonia (CAP). Cohort study including adult patients with CAP from two Spanish university-hospitals. SIRS, qSOFA, CRB (Confusion, Respiratory rate and Blood pressure), mSOFA, CURB-65 and Pneumonia Severity Index (PSI) were calculated with data from the emergency department. We used decision-curve analysis to evaluate the clinical usefulness of each score and the primary outcome was in-hospital mortality. Of 6,874 patients, 442 (6.4%) died in hospital. SIRS presented the worst discrimination, followed by qSOFA, CRB, mSOFA, CURB-65 and PSI. Overall, overestimation of in-hospital mortality and mis-calibration was more evident for qSOFA and mSOFA. SIRS had lower net benefit than qSOFA and CRB, significantly increasing the risk of over-treatment and being comparable to the "treat-all" strategy. PSI had higher net benefit than mSOFA and CURB-65 for mortality; while mSOFA seemed more applicable when considering mortality/ICU admission. Sepsis-3 flowchart resulted in better identification of patients at high risk of mortality. qSOFA and CRB outperformed SIRS and presented better clinical usefulness as prompt tools for CAP patients in the emergency department. Among the tools for a comprehensive patient assessment, PSI had the best decision-aid tool profile.

  5. [An aid to decision making in the treatment of furcation diseases. Part 1: Results of surgical treatment of furcation diseases].

    PubMed

    De Beule, F; Defleur, P; Bercy, P

    1998-01-01

    Periodontal diseases combined with furcation defects are more difficult to treat; it's evidence. Furcation defects occur still very frequently. GTR treatments have shown some efficacy in those lesions, but, the success of those treatments is still uncertain and, therefore, indications are limited. Root amputations are, at this time, frequently chosen to treat furcation defects. The goal of this work was to evaluate the success rate of root amputations, to discuss the origin of the failures and to propose a new design for a better decision making.

  6. [An aid to decision making in the treatment of furcation diseases. Part 2: New classifications and reasoning methods].

    PubMed

    De Beule, F; Defleur, P; Bercy, P

    1998-01-01

    Periodontal diseases combined with furcation defects are more difficult to treat; it's evidence. Furcation defects occur still very frequently. GTR treatments have shown some efficacy in those lesions, but, the success of those treatments is still uncertain and, therefore, indications are limited. Root amputations are, at this time, frequently chosen to treat furcation defects. The goal of this work was to evaluate the success rate of root amputations, to discuss the origin of the failures and to propose a new design for a better decision making.

  7. A Survey on Turkish nursing students' perception of clinical learning environment and its association with academic motivation and clinical decision making.

    PubMed

    Aktaş, Yeşim Yaman; Karabulut, Neziha

    2016-01-01

    Nursing education is a process that includes theoretical and practical learning and requires the acquisition of theoretical knowledge and skill. Nursing students need a good clinical practice environment in order to apply their knowledge and skills due to the fact that the clinical practice settings play an important role in the nursing profession. This study was carried out in an effort to explore nursing students' perception of the clinical learning environment and its association with academic motivation and clinical decision making. A descriptive survey design was used. This study was conducted in Giresun University in Turkey. Participants were second-, third- and fourth-year undergraduate students (n=222) in the Bachelor of Nursing Science Degree in the academic spring term of 2014-2015. The data was collected using the 'Clinical Learning Environment Scale', the 'Academic Motivation, and the 'The Clinical Decision Making in Nursing Scale'. Of the respondents in this study, 45% of the students were second class, 30.6% of the students were third class and 24.3% of the students were fourth class. There was a statistically significant positive correlation found between the clinical learning environment and the nursing students' academic motivation (r=0.182, p<.05). However, there was no correlation between the clinical learning environment and clinical decision making (r=0.082, p>.05). One of the prerequisites for the training of qualified students is to provide nursing students with a qualified clinical environment. It was found that nursing students' academic motivation increased as the quality of their clinical learning environment improved. Copyright © 2015 Elsevier Ltd. All rights reserved.

  8. The Role of Proteomics in Biomarker Development for Improved Patient Diagnosis and Clinical Decision Making in Prostate Cancer

    PubMed Central

    Tonry, Claire L.; Leacy, Emma; Raso, Cinzia; Finn, Stephen P.; Armstrong, John; Pennington, Stephen R.

    2016-01-01

    Prostate Cancer (PCa) is the second most commonly diagnosed cancer in men worldwide. Although increased expression of prostate-specific antigen (PSA) is an effective indicator for the recurrence of PCa, its intended use as a screening marker for PCa is of considerable controversy. Recent research efforts in the field of PCa biomarkers have focused on the identification of tissue and fluid-based biomarkers that would be better able to stratify those individuals diagnosed with PCa who (i) might best receive no treatment (active surveillance of the disease); (ii) would benefit from existing treatments; or (iii) those who are likely to succumb to disease recurrence and/or have aggressive disease. The growing demand for better prostate cancer biomarkers has coincided with the development of improved discovery and evaluation technologies for multiplexed measurement of proteins in bio-fluids and tissues. This review aims to (i) provide an overview of these technologies as well as describe some of the candidate PCa protein biomarkers that have been discovered using them; (ii) address some of the general limitations in the clinical evaluation and validation of protein biomarkers; and (iii) make recommendations for strategies that could be adopted to improve the successful development of protein biomarkers to deliver improvements in personalized PCa patient decision making. PMID:27438858

  9. Improving risk assessment of violence among military veterans: an evidence-based approach for clinical decision-making.

    PubMed

    Elbogen, Eric B; Fuller, Sara; Johnson, Sally C; Brooks, Stephanie; Kinneer, Patricia; Calhoun, Patrick S; Beckham, Jean C

    2010-08-01

    Increased media attention to post-deployment violence highlights the need to develop effective models to guide risk assessment among military Veterans. Ideally, a method would help identify which Veterans are most at risk for violence so that it can be determined what could be done to prevent violent behavior. This article suggests how empirical approaches to risk assessment used successfully in civilian populations can be applied to Veterans. A review was conducted of the scientific literature on Veteran populations regarding factors related to interpersonal violence generally and to domestic violence specifically. A checklist was then generated of empirically-supported risk factors for clinicians to consider in practice. To conceptualize how these known risk factors relate to a Veteran's violence potential, risk assessment scholarship was utilized to develop an evidence-based method to guide mental health professionals. The goals of this approach are to integrate science into practice, overcome logistical barriers, and permit more effective assessment, monitoring, and management of violence risk for clinicians working with Veterans, both in Department of Veteran Affairs settings and in the broader community. Research is needed to test the predictive validity of risk assessment models. Ultimately, the use of a systematic, empirical framework could lead to improved clinical decision-making in the area of risk assessment and potentially help prevent violence among Veterans.

  10. Improving risk assessment of violence among military Veterans: An evidence-based approach for clinical decision-making

    PubMed Central

    Elbogen, Eric B.; Fuller, Sara; Johnson, Sally C.; Brooks, Stephanie; Kinneer, Patricia; Calhoun, Patrick; Beckham, Jean C.

    2010-01-01

    Despite increased media attention on violent acts against others committed by military Veterans, few models have been developed to systematically guide violence risk assessment among Veterans. Ideally, a model would identify which Veterans are most at risk for violence and increased attention could then be turned to determining what could be done to prevent violent behavior. This article suggests how empirical approaches to risk assessment used successfully in civilian populations can be applied to Veterans. A review was conducted of the scientific literature on Veteran populations regarding factors related to interpersonal violence generally and to domestic violence specifically. A list was then generated of empirically-supported risk factors for clinicians to consider in practice. To conceptualize how these known risk factors relate to a Veteran’s violence potential, risk assessment scholarship was utilized to develop an evidence-based method to guide mental health professionals. The goals of this approach are to integrate science into practice, overcome logistical barriers, and permit more effective assessment, monitoring, and management of violence risk for clinicians working with Veterans, both in Veteran Administration settings and in the broader community. It is likely that the use of a systematic, empirical framework could lead to improved clinical decision-making in the area of risk assessment, and help reduce violence among Veterans. PMID:20627387

  11. The principles of Catholic social teaching: A guide for decision making from daily clinical encounters to national policy-making.

    PubMed

    Wright, Karen Shields

    2017-02-01

    Catholic social teaching (CST), a branch of moral theology, addresses contemporary issues within the political, economic, and cultural structures of society. The threefold cornerstone of CST contains the principles of human dignity, solidarity, and subsidiarity. It is the foundation on which to form our conscience in order to evaluate the framework of society and is the Catholic criteria for prudential judgment and direction in developing current policy-making. With knowledge of these social principles, in combination with our faith, we will be more armed and informed as to articulate the Catholic vision of reality, the truthful nature of the human person and society, to apply and integrate the social teachings in our everyday administrative and clinical encounters, and through the virtue of charity take action within the social, political, and economic spheres in which we have influence. Summary: The Church's social encyclicals are a reflection upon the issues of the day using the light of faith and reason. They offer commentary on the ways to evaluate and address particular social problems-also using natural law principles-in the areas of politics, economics, and culture. Quotes were selected from the encyclicals that define and expand upon the primary principles for the purpose of representing them for study, reflection, and use in everyday personal and business encounters and decision making for healthcare professionals.

  12. Development and validation of a self-efficacy scale for clinical decision-making in general paediatrics

    PubMed Central

    Dandavino, Mylène; Young, Meredith; Gosselin, Richard; Snell, Linda; Bhanji, Farhan

    2013-01-01

    BACKGROUND: Success in a task is not only related to skill, but it is also related to ‘self-efficacy’, or belief in one’s capability to perform that task. No tool currently exists to measure self-efficacy in clinical decision-making in general paediatrics. OBJECTIVE: To develop and provide validity evidence for the General Pediatrics-specific Self-Efficacy (GPedsSE) scale. METHODS: The five-item GPedsSE scale, developed using an expert panel, was matched to the New General Self-Efficacy (NGSE) scale’s structure for validity analysis purposes. Thirty-six postgraduate year 1 to postgraduate year 5 paediatric residents of the Montreal Children’s Hospital (Montreal, Quebec) completed the GPedsSE and NGSE scales, with items interspersed. RESULTS: The mean (± SD) GPedsSE score was 18.6±2.6 of 25. Total GPedsSE and NGSE scores were moderately correlated (r=0.54, P<0.005). On planned comparison, the GPedsSE score increased with training year (F[1.3]=6.62; P<0.001), while the NGSE score did not (F<0.37). Exploratory factor analysis showed two components, each aligning with a scale. CONCLUSION: The GPedsSE scale contextualizes an existing tool to general paediatrics, a novel concurrent validity approach. PMID:24421685

  13. Is it the time to rethink clinical decision-making strategies? From a single clinical outcome evaluation to a Clinical Multi-criteria Decision Assessment (CMDA).

    PubMed

    Migliore, Alberto; Integlia, Davide; Bizzi, Emanuele; Piaggio, Tomaso

    2015-10-01

    There are plenty of different clinical, organizational and economic parameters to consider in order having a complete assessment of the total impact of a pharmaceutical treatment. In the attempt to follow, a holistic approach aimed to provide an evaluation embracing all clinical parameters in order to choose the best treatments, it is necessary to compare and weight multiple criteria. Therefore, a change is required: we need to move from a decision-making context based on the assessment of one single criteria towards a transparent and systematic framework enabling decision makers to assess all relevant parameters simultaneously in order to choose the best treatment to use. In order to apply the MCDA methodology to clinical decision making the best pharmaceutical treatment (or medical devices) to use to treat a specific pathology, we suggest a specific application of the Multiple Criteria Decision Analysis for the purpose, like a Clinical Multi-criteria Decision Assessment CMDA. In CMDA, results from both meta-analysis and observational studies are used by a clinical consensus after attributing weights to specific domains and related parameters. The decision will result from a related comparison of all consequences (i.e., efficacy, safety, adherence, administration route) existing behind the choice to use a specific pharmacological treatment. The match will yield a score (in absolute value) that link each parameter with a specific intervention, and then a final score for each treatment. The higher is the final score; the most appropriate is the intervention to treat disease considering all criteria (domain an parameters). The results will allow the physician to evaluate the best clinical treatment for his patients considering at the same time all relevant criteria such as clinical effectiveness for all parameters and administration route. The use of CMDA model will yield a clear and complete indication of the best pharmaceutical treatment to use for patients

  14. Intravenous versus Oral Acetaminophen for Pain: Systematic Review of Current Evidence to Support Clinical Decision-Making

    PubMed Central

    Jibril, Farah; Sharaby, Sherif; Mohamed, Ahmed; Wilby, Kyle J

    2015-01-01

    Background: Intravenous (IV) acetaminophen is increasingly used around the world for pain control for a variety of indications. However, it is unclear whether IV administration offers advantages over oral administration. Objective: To identify, summarize, and critically evaluate the literature comparing analgesic efficacy, safety, and pharmacokinetics for IV and oral dosage forms of acetaminophen. Data Sources: A literature search of the PubMed, Embase, and International Pharmaceutical Abstracts databases was supplemented with keyword searches of Science Direct, Wiley Library Online, and Springer Link databases for the period 1948 to November 2014. The reference lists of identified studies were searched manually. Study Selection and Data Extraction: Randomized controlled trials comparing IV and oral dosage forms of acetaminophen were included if they assessed an efficacy, safety, or pharmacokinetic outcome. For each study, 2 investigators independently extracted data (study design, population, interventions, follow-up, efficacy outcomes, safety outcomes, pharmacokinetic outcomes, and any other pertinent information) and completed risk-of-bias assessments. Data Synthesis: Six randomized clinical trials were included. Three of the studies reported outcomes pertaining to efficacy, 4 to safety, and 4 to pharmacokinetics. No clinically significant differences in efficacy were found between the 2 dosage forms. Safety outcomes were not reported consistently enough to allow adequate assessment. No evidence was found to suggest that increased bioavailability of the IV formulation enhances efficacy outcomes. For studies reporting clinical outcomes, the results of risk-of-bias assessments were largely unclear. Conclusions: For patients who can take an oral dosage form, no clear indication exists for preferential prescribing of IV acetaminophen. Decision-making must take into account the known adverse effects of each dosage form and other considerations such as convenience and

  15. Evaluation of a clinical decision-making aid for nutrition advice in age-related macular degeneration.

    PubMed

    Stevens, Rebekah; Bartlett, Hannah; Cooke, Richard

    2017-09-01

    Age-related macular disease (AMD) is a multifactorial degenerative condition affecting the central area of the retina. Patients with AMD report that eye care practitioners are not giving consistent advice regarding nutrition and reported confusion as to what advice, if any, to follow. The aim of this study was to design and conduct a preliminary evaluation of a flowchart to support eye care practitioners in providing accurate, evidence-based nutritional advice to their patients. A flowchart was designed to take practitioners through a decision-making process that would determine whether a patient matched the Age-Related Eye Disease Study (AREDS) 2 eligibility criteria for supplementation. The flowchart was evaluated using a qualified and student optometrist cohort, with both cohorts completing confidence scales and students completing clinical scenarios. Qualified participants showed a significant increase in confidence scores from the initial survey (M = 69.7%, standard deviation [SD] = 16.2%) to the second survey after use of the flowchart for 2 weeks (M = 82.1%, SD = 11.6%; t(45) = 7.33, p < .001; rs = .61, p < .001). The student participants also increased confidence scored after receiving the flowchart (M of first survey = 41.7, SD = 14.6; M of second survey = 69.1, SD = 1.7; t(25) = 7.92, d = .81, p < .001) and increased the number of correct answers on five clinical scenarios. Overall, the flowchart has proved to be useful in boosting the self-efficacy of both qualified practitioners and student practitioners, as well as improving clinical decisions made by student practitioners.

  16. 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

  17. Developing CollaboRATE: a fast and frugal patient-reported measure of shared decision making in clinical encounters.

    PubMed

    Elwyn, Glyn; Barr, Paul James; Grande, Stuart W; Thompson, Rachel; Walsh, Thom; Ozanne, Elissa M

    2013-10-01

    Measuring the process of shared decision making is a challenge, which constitutes a barrier to research and implementation. The aim of the study was to report the development of CollaboRATE, brief patient-reported measure of shared decision making. We used the following stages: (1) item formulation; (2) cognitive interviews; (3) item refinement; and (4) pilot testing of final items. Participants were over 18 years old, recruited from the public areas of the Dartmouth-Hitchcock Medical Center. The key finding of this study is that developing a brief patient-reported measure of shared decision making requires a move away from terms such as 'decisions', 'options' and 'preferences'. Although technically correct, these terms act as barriers. They are often unfamiliar, and they also implicitly assume that patients are willing to take active roles in decision making; whereas patients are often unaware that decisions are required, or have taken place, never mind feel that they could or should have participated in them. These methods have allowed us to develop a brief, patient-reported measure of shared decision making that is highly accessible to intended users. The potential strength of the CollaboRATE will be the ability for completion in less than 30s, and across a range of routine settings. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

  18. Assessing the feasibility and quality of shared decision making in China: evaluating a clinical encounter intervention for Chinese patients

    PubMed Central

    Huang, Rongchong; Song, Xiantao; Wu, Jian; Huang, Wei; Leppin, Aaron L; Gionfriddo, Michael R; Liu, Yongxian; Boehmer, Kasey R; Ting, Henry H; Montori, Victor M

    2016-01-01

    Background The aim of this study was to evaluate the feasibility of using the Statin Choice decision aid to have discussions about starting a statin medication for cardiovascular risk reduction in Chinese patients with stable coronary artery diseases. Methods A prospective, pilot study of the Statin Choice decision aid in two teaching hospitals in Northern China was conducted. A total of seven clinicians were enrolled and underwent a 12-hour, group-based, in-person training on shared decision making (SDM) and the Statin Choice decision aid. Then, these clinicians used the Statin Choice decision aid in patients during a clinical encounter. A total of 86 patients aged 40−80 years, who had stable angina, were enrolled. All clinical encounters were video recorded. A team of three researchers viewed and scored all the encounter recordings to evaluate the SDM process and fidelity to the intervention using the OPTION scale and Fidelity scale, respectively. All the patients were followed up for 12 months to record adherence to statin and any major adverse cardiac events (MACEs). Results The average scores on the OPTION normalized score and Fidelity scale were 21 (range, 3–32; out of a possible, 48) and 10 (range, 6–10; out of a possible, 10), respectively. This suggested that Chinese clinicians who were using Statin Choice in their patients were able to exhibit behaviors consistent with SDM at a level that is similar to that reported in Western countries. After SDM, the statin adherence was 94.5% (69/73), and the proportion of MACEs was 2.9% (2/69). Conclusion Using an encounter decision aid developed in the US, it was feasible to implement SDM in a referral cardiology practice in Mainland China. Further work to ensure that the encounter aid is pertinent to the Chinese population and that SDM is tested in at-risk patients could contribute to the implementation of SDM across Mainland China. PMID:27881912

  19. Joint federal research and development process to meet state and local needs. Part 1. Science and technology and political decision making

    SciTech Connect

    Wise, H F; Smith, L K; Einsweiler, R C; Jensen, D E

    1980-10-01

    This part of the handbook addresses the basic how to do it - how states and local governments can identify complex and cross-cutting issues and develop and manage scientific and technical resources in seeking policy solutions to such issues. The following subjects are discussed: background statement of the issue; the research/decision-making process; defining problems and identifying research components; research and decision-making strategies; how to identify existing knowledge or ongoing research in the area of policy concern; and managing multi-disciplinary research. The fourteen agencies involved in this effort include: US Departments of Energy, Agriculture, Transportation, Housing and Urban Development, Environmental Protection Agency, and National Science Foundation. (PSB)

  20. The effect of the quality of vital sign recording on clinical decision making in a regional acute care trauma ward.

    PubMed

    Keene, Claire M; Kong, Victor Y; Clarke, Damian L; Brysiewicz, Petra

    2017-07-05

    Recording vital signs is important in the hospital setting and the quality of this documentation influences clinical decision making. The Modified Early Warning Score (MEWS) uses vital signs to categorise the severity of a patient's physiological derangement and illustrates the clinical impact of vital signs in detecting patient deterioration and making management decisions. This descriptive study measured the quality of vital sign recordings in an acute care trauma setting, and used the MEWS to determine the impact the documentation quality had on the detection of physiological derangements and thus, clinical decision making. Vital signs recorded by the nursing staff of all trauma patients in the acute care trauma wards at a regional hospital in South Africa were collected from January 2013 to February 2013. Investigator-measured values taken within 2 hours of the routine observations and baseline patient information were also recorded. A MEWS for each patient was calculated from the routine and investigator-measured observations. Basic descriptive statistics were performed using EXCEL. The details of 181 newly admitted patients were collected. Completion of recordings was 81% for heart rate, 88% for respiratory rate, 98% for blood pressure, 92% for temperature and 41% for GCS. The recorded heart rate was positively correlated with the investigator's measurement (Pearson's correlation coefficient of 0.76); while the respiratory rate did not correlate (Pearson's correlation coefficient of 0.02). In 59% of patients the recorded respiratory rate (RR) was exactly 20 breaths per minute and 27% had a recorded RR of exactly 15. Seven percent of patients had aberrant Glasgow Coma Scale readings above the maximum value of 15. The average MEWS was 2 for both the recorded (MEWS(R)) and investigator (MEWS(I)) vitals, with the range of MEWS(R) 0-7 and MEWS(I) 0-9. Analysis showed 59% of the MEWS(R) underestimated the physiological derangement (scores were lower than the MEWS

  1. Leveraging certified nursing assistant documentation and knowledge to improve clinical decision making: the on-time quality improvement program to prevent pressure ulcers.

    PubMed

    Sharkey, Siobhan; Hudak, Sandra; Horn, Susan D; Spector, William

    2011-04-01

    The goal of this article was to enhance understanding of the On-Time Quality Improvement for Long-term Care Program, a practical approach to embed health information technology into quality improvement in nursing homes that leverages certified nursing assistant documentation and knowledge, supports frontline clinical decision making, and establishes proactive intervention for pressure ulcer prevention.

  2. 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…

  3. 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…

  4. The effect of clinical judgment in decision-making: the Mental Health Act 1986 (Vic.) and the Mental Health Review Board.

    PubMed

    Pearson, Megan

    2006-01-01

    This article seeks to critically examine whether the reliance upon clinical judgment in decision-making under the Mental Health Act 1986 (Vic.) (MHA) and the Mental Health Review Board (MHRB) assists or hinders Parliament's key objective in passing the current MHA in 1986: least restrictive treatment.

  5. Ten myths about decision-making capacity.

    PubMed

    Ganzini, Linda; Volicer, Ladislav; Nelson, William A; Fox, Ellen; Derse, Arthur R

    2005-01-01

    As a matter of practical reality, what role patients will play in decisions about their health care is determined by whether their clinicians judge them to have decision-making capacity. Because so much hinges on assessments of capacity, clinicians who work with patients have an ethical obligation to understand this concept. This article, based on a report prepared by the National Ethics Committee (NEC) of the Veterans Health Administration (VHA), seeks to provide clinicians with practical information about decision-making capacity and how it is assessed. A study of clinicians and ethics committee chairs carried out under the auspices of the NEC identified the following 10 common myths clinicians hold about decision-making capacity: (1) decision-making capacity and competency are the same; (2) lack of decision-making capacity can be presumed when patients go against medical advice; (3) there is no need to assess decision-making capacity unless patients go against medical advice; (4) decision-making capacity is an "all or nothing" phenomenon; (5) cognitive impairment equals lack of decision-making capacity; (6) lack of decision-making capacity is a permanent condition; (7) patients who have not been given relevant and consistent information about their treatment lack decision-making capacity; (8) all patients with certain psychiatric disorders lack decision-making capacity; (9) patients who are involuntarily committed lack decision-making capacity; and (10) only mental health experts can assess decision-making capacity. By describing and debunking these common misconceptions, this article attempts to prevent potential errors in the clinical assessment of decision-making capacity, thereby supporting patients' right to make choices about their own health care.

  6. Ten myths about decision-making capacity.

    PubMed

    Ganzini, Linda; Volicer, Ladislav; Nelson, William A; Fox, Ellen; Derse, Arthur R

    2004-01-01

    As a matter of practical reality, what role patients will play in decisions about their health care is determined by whether their clinicians judge them to have decision-making capacity. Because so much hinges on assessments of capacity, clinicians who work with patients have an ethical obligation to understand this concept. This article, based on a report prepared by the National Ethics Committee (NEC) of the Veterans Health Administration (VHA), seeks to provide clinicians with practical information about decision-making capacity and how it is assessed. A study of clinicians and ethics committee chairs carried out under the auspices of the NEC identified the following 10 common myths clinicians hold about decision-making capacity: (1) decision-making capacity and competency are the same; (2) lack of decision-making capacity can be presumed when patients go against medical advice; (3) there is no need to assess decision-making capacity unless patients go against medical advice; (4) decision-making capacity is an "all or nothing" phenomenon; (5) cognitive impairment equals lack of decision-making capacity; (6) lack of decision-making capacity is a permanent condition; (7) patients who have not been given relevant and consistent information about their treatment lack decision-making capacity; (8) all patients with certain psychiatric disorders lack decision-making capacity; (9) patients who are involuntarily committed lack decision-making capacity; and (10) only mental health experts can assess decision-making capacity. By describing and debunking these common misconceptions, this article attempts to prevent potential errors in the clinical assessment of decision-making capacity, thereby supporting patients' right to make choices about their own health care.

  7. Genetic Analysis of Arrhythmogenic Diseases in the Era of NGS: The Complexity of Clinical Decision-Making in Brugada Syndrome

    PubMed Central

    Allegue, Catarina; Coll, Mònica; Mates, Jesus; Campuzano, Oscar; Iglesias, Anna; Sobrino, Beatriz; Brion, Maria; Amigo, Jorge; Carracedo, Angel; Brugada, Pedro; Brugada, Josep; Brugada, Ramon

    2015-01-01

    purposes due to the large amount of data generated. The identification of these genetic variants opens new perspectives on the implications of genetic background in the arrhythmogenic substrate for research purposes. Conclusions As a paradigm for other arrhythmogenic diseases and for unexplained sudden death, our data show that clinical genetic diagnosis is justified in a family perspective for confirmation of genetic causality. In the era of personalized medicine using high-throughput tools, clinical decision-making is increasingly complex. PMID:26230511

  8. Attitude of cancer patients toward diagnosis disclosure and their preference for clinical decision-making: a national survey.

    PubMed

    Motlagh, Ali; Yaraei, Neda; Mafi, Ahmad R; Hosseini Kamal, Farnaz; Yaseri, Mehdi; Hemati, Simin; Shahbazian, Hojatollah; Sedighi, Abdol-Azim; Khodabakhshi, Reza; Taghizadeh, Ali; Ansari, Jamshid; Seyednejad, Farshad; Khanduzi, Reza; Mojir Sheibani, Khosro; Azadeh, Payam; Emranpour, Mohamad Hasan; Mosalei, Ahmad; Vojdani, Soheil; Nazari, Ali Mohamad; Nazarimenesh, Leila; Fazl-Alizadeh, Abdolah; Akbari, Mohamad Esmaeil

    2014-04-01

    There is still contradictory evidence on disclosure preferences regarding cancer diagnosis. The aim of this study was to evaluate the preference of cancer patients for knowing the truth about their disease, as well as the factors that might have an impact on these preferences. This study was conducted in 11 cancer centers in Iran. A questionnaire was used to collect data, and all patients above 15 years of age who were willing to participate were included in the study. The patients were asked if they were aware of the malignant nature of their disease, and if they came to know about their disease at the time of initial diagnosis, or later. The patients were then asked about the way they looked upon their disease. In the final part of the questionnaire, the participants were asked the level of involvement they prefer to have in making treatment decisions. In total, 1226 patients were enrolled in this study, only 565 (46.7%) of whom were aware of their disease at the time of diagnosis, and 878 (72.7%) at the time of interview, while 980 (85.2%) were willing to receive information about their disease. Patients' awareness was significantly associated with age under 50 years, female gender, having breast, skin or head and neck cancer, and having medical care in Shiraz or Hamadan while it was not associated with the stage or accompanying illness. While the majority of Iranian cancer patients prefer to be aware of the nature of their disease and have an active role in treatment decision making, they do not receive this information.

  9. Patient-Specific Computational Modeling of Upper Extremity Arteriovenous Fistula Creation: Its Feasibility to Support Clinical Decision-Making

    PubMed Central

    Bosboom, E. Marielle H.; Kroon, Wilco; van der Linden, Wim P. M.; Planken, R. Nils; van de Vosse, Frans N.; Tordoir, Jan H. M.

    2012-01-01

    Introduction Inadequate flow enhancement on the one hand, and excessive flow enhancement on the other hand, remain frequent complications of arteriovenous fistula (AVF) creation, and hamper hemodialysis therapy in patients with end-stage renal disease. In an effort to reduce these, a patient-specific computational model, capable of predicting postoperative flow, has been developed. The purpose of this study was to determine the accuracy of the patient-specific model and to investigate its feasibility to support decision-making in AVF surgery. Methods Patient-specific pulse wave propagation models were created for 25 patients awaiting AVF creation. Model input parameters were obtained from clinical measurements and literature. For every patient, a radiocephalic AVF, a brachiocephalic AVF, and a brachiobasilic AVF configuration were simulated and analyzed for their postoperative flow. The most distal configuration with a predicted flow between 400 and 1500 ml/min was considered the preferred location for AVF surgery. The suggestion of the model was compared to the choice of an experienced vascular surgeon. Furthermore, predicted flows were compared to measured postoperative flows. Results Taken into account the confidence interval (25th and 75th percentile interval), overlap between predicted and measured postoperative flows was observed in 70% of the patients. Differentiation between upper and lower arm configuration was similar in 76% of the patients, whereas discrimination between two upper arm AVF configurations was more difficult. In 3 patients the surgeon created an upper arm AVF, while model based predictions allowed for lower arm AVF creation, thereby preserving proximal vessels. In one patient early thrombosis in a radiocephalic AVF was observed which might have been indicated by the low predicted postoperative flow. Conclusions Postoperative flow can be predicted relatively accurately for multiple AVF configurations by using computational modeling. This

  10. Validation of a nomogram for predicting regression from impaired fasting glucose to normoglycaemia to facilitate clinical decision making

    PubMed Central

    Guo, Vivian YW; Yu, Esther YT; Wong, Carlos KH; Sit, Regina WS; Wang, Jenny HL; Ho, SY; Lam, Cindy LK

    2016-01-01

    Background. In Hong Kong, fasting plasma glucose (FPG) is the most popular screening test for diabetes mellitus (DM) in primary care. Individuals with impaired fasting glucose (IFG) are commonly encountered. Objectives. To explore the determinants of regression to normoglycaemia among primary care patients with IFG based on non-invasive variables and to establish a nomogram for the prediction of regression from IFG. Methods. This cohort study consisted of 1197 primary care patients with IFG. These subjects were invited to repeat a FPG test and 75-g 2-hour oral glucose tolerance test (2h-OGTT) to determine the glycaemia change. Normoglycaemia was defined as FPG <5.6 mmol/L and 2h-OGTT <7.8 mmol/L. Stepwise logistic regression model was developed to predict the regression to normoglycaemia with non-invasive variables, using a randomly selected training dataset (810 subjects). The model was validated on the remaining testing dataset (387 subjects). Area under the receiver operating characteristic curve (AUC) and Hosmer–Lemeshow test were used to evaluate discrimination and calibration of the model. A nomogram was constructed based on the model. Results. After a mean follow-up period of 6.1 months, 180 subjects (15.0%) had normoglycaemia based on the repeated FPG and 2h-OGTT results at follow-up. Subjects without central obesity or hypertension, with moderate-to-high-level physical activity and a lower baseline FPG level, were more likely to regress to normoglycaemia. The prediction model had acceptable discrimination (AUC = 0.705) and calibration (P = 0.840). Conclusion. The simple-to-use nomogram could facilitate identification of subjects with low risk of progression to DM and thus aid in clinical decision making and resource prioritization in the primary care setting. PMID:27142313

  11. Validation of a nomogram for predicting regression from impaired fasting glucose to normoglycaemia to facilitate clinical decision making.

    PubMed

    Guo, Vivian Yw; Yu, Esther Yt; Wong, Carlos Kh; Sit, Regina Ws; Wang, Jenny Hl; Ho, S Y; Lam, Cindy Lk

    2016-08-01

    In Hong Kong, fasting plasma glucose (FPG) is the most popular screening test for diabetes mellitus (DM) in primary care. Individuals with impaired fasting glucose (IFG) are commonly encountered. To explore the determinants of regression to normoglycaemia among primary care patients with IFG based on non-invasive variables and to establish a nomogram for the prediction of regression from IFG. This cohort study consisted of 1197 primary care patients with IFG. These subjects were invited to repeat a FPG test and 75-g 2-hour oral glucose tolerance test (2h-OGTT) to determine the glycaemia change. Normoglycaemia was defined as FPG <5.6 mmol/L and 2h-OGTT <7.8 mmol/L. Stepwise logistic regression model was developed to predict the regression to normoglycaemia with non-invasive variables, using a randomly selected training dataset (810 subjects). The model was validated on the remaining testing dataset (387 subjects). Area under the receiver operating characteristic curve (AUC) and Hosmer-Lemeshow test were used to evaluate discrimination and calibration of the model. A nomogram was constructed based on the model. After a mean follow-up period of 6.1 months, 180 subjects (15.0%) had normoglycaemia based on the repeated FPG and 2h-OGTT results at follow-up. Subjects without central obesity or hypertension, with moderate-to-high-level physical activity and a lower baseline FPG level, were more likely to regress to normoglycaemia. The prediction model had acceptable discrimination (AUC = 0.705) and calibration (P = 0.840). The simple-to-use nomogram could facilitate identification of subjects with low risk of progression to DM and thus aid in clinical decision making and resource prioritization in the primary care setting. © The Author 2016. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

  12. 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.

  13. 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.

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

    SciTech Connect

    Shakespeare, Thomas P. . E-mail: ThomasShakespeare@gmail.com; Back, Michael F.; Lu, Jiade J.; Lee, Khai Mun; Mukherjee, Rahul K.

    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/quality 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.

  15. Multi-criteria clinical decision support: A primer on the use of multiple criteria decision making methods to promote evidence-based, patient-centered healthcare.

    PubMed

    Dolan, James G

    2010-01-01

    Current models of healthcare quality recommend that patient management decisions be evidence-based and patient-centered. Evidence-based decisions require a thorough understanding of current information regarding the natural history of disease and the anticipated outcomes of different management options. Patient-centered decisions incorporate patient preferences, values, and unique personal circumstances into the decision making process and actively involve both patients along with health care providers as much as possible. Fundamentally, therefore, evidence-based, patient-centered decisions are multi-dimensional and typically involve multiple decision makers.Advances in the decision sciences have led to the development of a number of multiple criteria decision making methods. These multi-criteria methods are designed to help people make better choices when faced with complex decisions involving several dimensions. They are especially helpful when there is a need to combine "hard data" with subjective preferences, to make trade-offs between desired outcomes, and to involve multiple decision makers. Evidence-based, patient-centered clinical decision making has all of these characteristics. This close match suggests that clinical decision support systems based on multi-criteria decision making techniques have the potential to enable patients and providers to carry out the tasks required to implement evidence-based, patient-centered care effectively and efficiently in clinical settings.The goal of this paper is to give readers a general introduction to the range of multi-criteria methods available and show how they could be used to support clinical decision-making. Methods discussed include the balance sheet, the even swap method, ordinal ranking methods, direct weighting methods, multi-attribute decision analysis, and the analytic hierarchy process (AHP).

  16. Multi-criteria clinical decision support: A primer on the use of multiple criteria decision making methods to promote evidence-based, patient-centered healthcare

    PubMed Central

    Dolan, James G.

    2010-01-01

    Current models of healthcare quality recommend that patient management decisions be evidence-based and patient-centered. Evidence-based decisions require a thorough understanding of current information regarding the natural history of disease and the anticipated outcomes of different management options. Patient-centered decisions incorporate patient preferences, values, and unique personal circumstances into the decision making process and actively involve both patients along with health care providers as much as possible. Fundamentally, therefore, evidence-based, patient-centered decisions are multi-dimensional and typically involve multiple decision makers. Advances in the decision sciences have led to the development of a number of multiple criteria decision making methods. These multi-criteria methods are designed to help people make better choices when faced with complex decisions involving several dimensions. They are especially helpful when there is a need to combine “hard data” with subjective preferences, to make trade-offs between desired outcomes, and to involve multiple decision makers. Evidence-based, patient-centered clinical decision making has all of these characteristics. This close match suggests that clinical decision support systems based on multi-criteria decision making techniques have the potential to enable patients and providers to carry out the tasks required to implement evidence-based, patient-centered care effectively and efficiently in clinical settings. The goal of this paper is to give readers a general introduction to the range of multi-criteria methods available and show how they could be used to support clinical decision-making. Methods discussed include the balance sheet, the even swap method, ordinal ranking methods, direct weighting methods, multi-attribute decision analysis, and the analytic hierarchy process (AHP) PMID:21394218

  17. Informed Consent in Decision-Making in Pediatric Practice.

    PubMed

    Katz, Aviva L; Webb, Sally A

    2016-08-01

    Informed consent should be seen as an essential part of health care practice; parental permission and childhood assent is an active process that engages patients, both adults and children, in their health care. Pediatric practice is unique in that developmental maturation allows, over time, for increasing inclusion of the child's and adolescent's opinion in medical decision-making in clinical practice and research. This technical report, which accompanies the policy statement "Informed Consent in Decision-Making in Pediatric Practice" was written to provide a broader background on the nature of informed consent, surrogate decision-making in pediatric practice, information on child and adolescent decision-making, and special issues in adolescent informed consent, assent, and refusal. It is anticipated that this information will help provide support for the recommendations included in the policy statement. Copyright © 2016 by the American Academy of Pediatrics.

  18. The Role of Physiotherapy Extended Scope Practitioners in Musculoskeletal care with Focus on Decision Making and Clinical Outcomes: A Systematic Review of Quantitative and Qualitative Research.

    PubMed

    Thompson, Jonathan; Yoward, Samantha; Dawson, Pamela

    2017-06-01

    Physiotherapy extended scope practitioner (ESP) roles are widely utilized in the management of musculoskeletal conditions. The present article reviews the current literature, with particular emphasis on the decision-making process, patient/clinician interaction and clinical outcomes. A systematic review of musculoskeletal extended scope practice was carried out. The review focused on the outcome of interventions, and the interactions and decision-making processes between ESPs and their patients. A wide search strategy was employed, through multiple databases, grey literature and experts in the field. Qualitative and quantitative studies alike were included and a mixed-methods synthesis approach was undertaken in analysing the findings of included studies. A total of 476 articles were identified for inclusion, 25 of which (22 quantitative and three qualitative) meeting the criteria for full quality appraisal and synthesis. It was not possible to conduct a meta-analysis owing to data heterogeneity. The results showed high patient satisfaction with the ESP role, support for ESP staff listing patients for orthopaedic surgery, a high positive correlation of decision making between ESPs and orthopaedic surgeons and evidence of a positive impact on patient outcomes. Qualitative themes reflected the importance of ESP clinical decision making and interpersonal skills and their role in patient education. There is broad support for the physiotherapy ESP role and evidence of favourable outcomes from ESP intervention. Clinical decisions made by ESPs correlate well with those of medical colleagues, although there is a lack of detail explaining the ESP decision-making process itself and the influences and mechanisms by which this occurs. Copyright © 2016 John Wiley & Sons, Ltd. Copyright © 2016 John Wiley & Sons, Ltd.

  19. Decision Making in Action

    NASA Technical Reports Server (NTRS)

    Orasanu, Judith; Statler, Irving C. (Technical Monitor)

    1994-01-01

    The importance of decision-making to safety in complex, dynamic environments like mission control centers and offshore installations has been well established. NASA-ARC has a program of research dedicated to fostering safe and effective decision-making in the manned spaceflight environment. Because access to spaceflight is limited, environments with similar characteristics, including aviation and nuclear power plants, serve as analogs from which space-relevant data can be gathered and theories developed. Analyses of aviation accidents cite crew judgement and decision making as causes or contributing factors in over half of all accidents. A similar observation has been made in nuclear power plants. Yet laboratory research on decision making has not proven especially helpful in improving the quality of decisions in these kinds of environments. One reason is that the traditional, analytic decision models are inappropriate to multidimensional, high-risk environments, and do not accurately describe what expert human decision makers do when they make decisions that have consequences. A new model of dynamic, naturalistic decision making is offered that may prove useful for improving decision making in complex, isolated, confined and high-risk environments. Based on analyses of crew performance in full-mission simulators and accident reports, features that define effective decision strategies in abnormal or emergency situations have been identified. These include accurate situation assessment (including time and risk assessment), appreciation of the complexity of the problem, sensitivity to constraints on the decision, timeliness of the response, and use of adequate information. More effective crews also manage their workload to provide themselves with time and resources to make good decisions. In brief, good decisions are appropriate to the demands of the situation. Effective crew decision making and overall performance are mediated by crew communication. Communication

  20. Emotion and decision making.

    PubMed

    Lerner, Jennifer S; Li, Ye; Valdesolo, Piercarlo; Kassam, Karim S

    2015-01-03

    A revolution in the science of emotion has emerged in recent decades, with the potential to create a paradigm shift in decision theories. The research reveals that emotions constitute potent, pervasive, predictable, sometimes harmful and sometimes beneficial drivers of decision making. Across different domains, important regularities appear in the mechanisms through which emotions influence judgments and choices. We organize and analyze what has been learned from the past 35 years of work on emotion and decision making. In so doing, we propose the emotion-imbued choice model, which accounts for inputs from traditional rational choice theory and from newer emotion research, synthesizing scientific models.

  1. Decision Making in Action

    NASA Technical Reports Server (NTRS)

    Orasanu, Judith; Statler, Irving C. (Technical Monitor)

    1994-01-01

    The importance of decision-making to safety in complex, dynamic environments like mission control centers and offshore installations has been well established. NASA-ARC has a program of research dedicated to fostering safe and effective decision-making in the manned spaceflight environment. Because access to spaceflight is limited, environments with similar characteristics, including aviation and nuclear power plants, serve as analogs from which space-relevant data can be gathered and theories developed. Analyses of aviation accidents cite crew judgement and decision making as causes or contributing factors in over half of all accidents. A similar observation has been made in nuclear power plants. Yet laboratory research on decision making has not proven especially helpful in improving the quality of decisions in these kinds of environments. One reason is that the traditional, analytic decision models are inappropriate to multidimensional, high-risk environments, and do not accurately describe what expert human decision makers do when they make decisions that have consequences. A new model of dynamic, naturalistic decision making is offered that may prove useful for improving decision making in complex, isolated, confined and high-risk environments. Based on analyses of crew performance in full-mission simulators and accident reports, features that define effective decision strategies in abnormal or emergency situations have been identified. These include accurate situation assessment (including time and risk assessment), appreciation of the complexity of the problem, sensitivity to constraints on the decision, timeliness of the response, and use of adequate information. More effective crews also manage their workload to provide themselves with time and resources to make good decisions. In brief, good decisions are appropriate to the demands of the situation. Effective crew decision making and overall performance are mediated by crew communication. Communication

  2. 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.

  3. Nottingham Prognostic Index Plus: Validation of a clinical decision making tool in breast cancer in an independent series

    PubMed Central

    Green, Andrew R; Soria, Daniele; Stephen, Jacqueline; Powe, Desmond G; Nolan, Christopher C; Kunkler, Ian; Thomas, Jeremy; Kerr, Gillian R; Jack, Wilma; Cameron, David; Piper, Tammy; Ball, Graham R; Garibaldi, Jonathan M; Rakha, Emad A; Bartlett, John MS

    2016-01-01

    Abstract The Nottingham Prognostic Index Plus (NPI+) is a clinical decision making tool in breast cancer (BC) that aims to provide improved patient outcome stratification superior to the traditional NPI. This study aimed to validate the NPI+ in an independent series of BC. Eight hundred and eighty five primary early stage BC cases from Edinburgh were semi‐quantitatively assessed for 10 biomarkers [Estrogen Receptor (ER), Progesterone Receptor (PgR), cytokeratin (CK) 5/6, CK7/8, epidermal growth factor receptor (EGFR), HER2, HER3, HER4, p53, and Mucin 1] using immunohistochemistry and classified into biological classes by fuzzy logic‐derived algorithms previously developed in the Nottingham series. Subsequently, NPI+ Prognostic Groups (PGs) were assigned for each class using bespoke NPI‐like formulae, previously developed in each NPI+ biological class of the Nottingham series, utilising clinicopathological parameters: number of positive nodes, pathological tumour size, stage, tubule formation, nuclear pleomorphism and mitotic counts. Biological classes and PGs were compared between the Edinburgh and Nottingham series using Cramer's V and their role in patient outcome prediction using Kaplan–Meier curves and tested using Log Rank. The NPI+ biomarker panel classified the Edinburgh series into seven biological classes similar to the Nottingham series (p > 0.01). The biological classes were significantly associated with patient outcome (p < 0.001). PGs were comparable in predicting patient outcome between series in Luminal A, Basal p53 altered, HER2+/ER+ tumours (p > 0.01). The good PGs were similarly validated in Luminal B, Basal p53 normal, HER2+/ER− tumours and the poor PG in the Luminal N class (p > 0.01). Due to small patient numbers assigned to the remaining PGs, Luminal N, Luminal B, Basal p53 normal and HER2+/ER− classes could not be validated. This study demonstrates the reproducibility of NPI+ and confirmed its prognostic value in

  4. Nottingham Prognostic Index Plus: Validation of a clinical decision making tool in breast cancer in an independent series.

    PubMed

    Green, Andrew R; Soria, Daniele; Stephen, Jacqueline; Powe, Desmond G; Nolan, Christopher C; Kunkler, Ian; Thomas, Jeremy; Kerr, Gillian R; Jack, Wilma; Cameron, David; Piper, Tammy; Ball, Graham R; Garibaldi, Jonathan M; Rakha, Emad A; Bartlett, John Ms; Ellis, Ian O

    2016-01-01

    The Nottingham Prognostic Index Plus (NPI+) is a clinical decision making tool in breast cancer (BC) that aims to provide improved patient outcome stratification superior to the traditional NPI. This study aimed to validate the NPI+ in an independent series of BC. Eight hundred and eighty five primary early stage BC cases from Edinburgh were semi-quantitatively assessed for 10 biomarkers [Estrogen Receptor (ER), Progesterone Receptor (PgR), cytokeratin (CK) 5/6, CK7/8, epidermal growth factor receptor (EGFR), HER2, HER3, HER4, p53, and Mucin 1] using immunohistochemistry and classified into biological classes by fuzzy logic-derived algorithms previously developed in the Nottingham series. Subsequently, NPI+ Prognostic Groups (PGs) were assigned for each class using bespoke NPI-like formulae, previously developed in each NPI+ biological class of the Nottingham series, utilising clinicopathological parameters: number of positive nodes, pathological tumour size, stage, tubule formation, nuclear pleomorphism and mitotic counts. Biological classes and PGs were compared between the Edinburgh and Nottingham series using Cramer's V and their role in patient outcome prediction using Kaplan-Meier curves and tested using Log Rank. The NPI+ biomarker panel classified the Edinburgh series into seven biological classes similar to the Nottingham series (p > 0.01). The biological classes were significantly associated with patient outcome (p < 0.001). PGs were comparable in predicting patient outcome between series in Luminal A, Basal p53 altered, HER2+/ER+ tumours (p > 0.01). The good PGs were similarly validated in Luminal B, Basal p53 normal, HER2+/ER- tumours and the poor PG in the Luminal N class (p > 0.01). Due to small patient numbers assigned to the remaining PGs, Luminal N, Luminal B, Basal p53 normal and HER2+/ER- classes could not be validated. This study demonstrates the reproducibility of NPI+ and confirmed its prognostic value in an independent cohort

  5. [Clinical everyday ethics-support in handling moral distress? : Evaluation of an ethical decision-making model for interprofessional clinical teams].

    PubMed

    Tanner, S; Albisser Schleger, H; Meyer-Zehnder, B; Schnurrer, V; Reiter-Theil, S; Pargger, H

    2014-06-01

    High-tech medicine and cost rationing provoke moral distress up to burnout syndromes. The consequences are severe, not only for those directly involved but also for the quality of patient care and the institutions. The multimodal model METAP (Modular, Ethical, Treatment, Allocation, Process) was developed as clinical everyday ethics to support the interprofessional ethical decision-making process. The distinctive feature of the model lays in education concerning ethics competence in dealing with difficult treatment decisions. METAP has been evaluated for quality testing. The research question of interest was whether METAP supports the handling of moral distress. The evaluation included 3 intensive care units and 3 geriatric units. In all, 33 single and 9 group interviews were held with 24 physicians, 44 nurses, and 9 persons from other disciplines. An additional questionnaire was completed by 122 persons (return rate 57%). Two-thirds of the interview answers and 55% of the questionnaire findings show that clinical everyday ethics supports the handling of moral distress, especially for interdisciplinary communication and collaboration and for the explanation and evaluation of treatment goals. METAP does not provide support for persons who are rarely confronted with ethical problems or have not applied the model long enough yet. To a certain degree, moral distress is unavoidable and must be addressed as an interprofessional problem. Herein, clinical everyday ethics may provide targeted support for ethical decision-making competence.

  6. Does CT-based Rigidity Analysis Influence Clinical Decision-making in Simulations of Metastatic Bone Disease?

    PubMed

    Nazarian, Ara; Entezari, Vahid; Villa-Camacho, Juan C; Zurakowski, David; Katz, Jeffrey N; Hochman, Mary; Baldini, Elizabeth H; Vartanians, Vartan; Rosen, Max P; Gebhardt, Mark C; Terek, Richard M; Damron, Timothy A; Yaszemski, Michael J; Snyder, Brian D

    2016-03-01

    There is a need to improve the prediction of fracture risk for patients with metastatic bone disease. CT-based rigidity analysis (CTRA) is a sensitive and specific method, yet its influence on clinical decision-making has never been quantified. What is the influence of CTRA on providers' perceived risk of fracture? (2) What is the influence of CTRA on providers' treatment recommendations in simulated clinical scenarios of metastatic bone disease of the femur? (3) Does CTRA improve interobserver agreement regarding treatment recommendations? We conducted a survey among 80 academic physicians (orthopaedic oncologists, musculoskeletal radiologists, and radiation oncologists) using simulated vignettes of femoral lesions presented as three separate scenarios: (1) no CTRA input (baseline); (2) CTRA input suggesting increased risk of fracture (CTRA+); and (3) CTRA input suggesting decreased risk of fracture (CTRA-). Participants were asked to rate the patient's risk of fracture on a scale of 0% to 100% and to provide a treatment recommendation. Overall response rate was 62.5% (50 of 80). When CTRA suggested an increased risk of fracture, physicians perceived the fracture risk to be slightly greater (37% ± 3% versus 42% ± 3%, p < 0.001; mean difference [95% confidence interval {CI}] = 5% [4.7%-5.2%]) and were more prone to recommend surgical stabilization (46% ± 9% versus 54% ± 9%, p < 0.001; mean difference [95% CI] = 9% [7.9-10.1]). When CTRA suggested a decreased risk of fracture, physicians perceived the risk to be slightly decreased (37% ± 25% versus 35% ± 25%, p = 0.04; mean difference [95% CI] = 2% [2.74%-2.26%]) and were less prone to recommend surgical stabilization (46% ± 9% versus 42% ± 9%, p < 0.03; mean difference [95% CI] = 4% [3.9-5.1]). The effect size of the influence of CTRA on physicians' perception of fracture risk and treatment planning varied with lesion severity and specialty of the responders. CTRA did not increase interobserver agreement

  7. Designing for Decision Making

    ERIC Educational Resources Information Center

    Jonassen, David H.

    2012-01-01

    Decision making is the most common kind of problem solving. It is also an important component skill in other more ill-structured and complex kinds of problem solving, including policy problems and design problems. There are different kinds of decisions, including choices, acceptances, evaluations, and constructions. After describing the centrality…

  8. Sustainability Based Decision Making

    EPA Science Inventory

    With sustainability as the “true north” for EPA research, a premium is placed on the ability to make decisions under highly complex and uncertain conditions. The primary challenge is reconciling disparate criteria toward credible and defensible decisions. Making decisions on on...

  9. Participative Decision-Making.

    ERIC Educational Resources Information Center

    Lindelow, John; And Others

    Chapter 6 in a volume on school leadership, this chapter makes a case for the use of participative decision-making (PDM) at the school-site level, outlines guidelines for its implementation, and describes the experiences of some schools with PDM systems. It begins by citing research indicating the advantages of PDM, including better decisions,…

  10. Repeated Causal Decision Making

    ERIC Educational Resources Information Center

    Hagmayer, York; Meder, Bjorn

    2013-01-01

    Many of our decisions refer to actions that have a causal impact on the external environment. Such actions may not only allow for the mere learning of expected values or utilities but also for acquiring knowledge about the causal structure of our world. We used a repeated decision-making paradigm to examine what kind of knowledge people acquire in…

  11. Quantitative Decision Making.

    ERIC Educational Resources Information Center

    Baldwin, Grover H.

    The use of quantitative decision making tools provides the decision maker with a range of alternatives among which to decide, permits acceptance and use of the optimal solution, and decreases risk. Training line administrators in the use of these tools can help school business officials obtain reliable information upon which to base district…

  12. Decision Making In Orienteering.

    ERIC Educational Resources Information Center

    Almeida, Katia

    1997-01-01

    Eight psychometric instruments were administered to 10 elite male Portuguese orienteers. The cognitive process involved in decision making did not differ between the best orienteers and the others. This group of athletes had a high capacity for work realization and a strong need to be in control of interpersonal situations. (Author/SV)

  13. Sustainability Based Decision Making

    EPA Science Inventory

    With sustainability as the “true north” for EPA research, a premium is placed on the ability to make decisions under highly complex and uncertain conditions. The primary challenge is reconciling disparate criteria toward credible and defensible decisions. Making decisions on on...

  14. Shared Decision Making.

    ERIC Educational Resources Information Center

    Lashway, Larry

    1997-01-01

    In shared decision making (SDM), principals collaborate with teachers and sometimes parents to take actions aimed at improving instruction and school climate. While research on SDM outcomes is still inconclusive, the literature shows that SDM brings both benefits and problems, and that the principal is a key figure. This brief offers a sampling of…

  15. Designing for Decision Making

    ERIC Educational Resources Information Center

    Jonassen, David H.

    2012-01-01

    Decision making is the most common kind of problem solving. It is also an important component skill in other more ill-structured and complex kinds of problem solving, including policy problems and design problems. There are different kinds of decisions, including choices, acceptances, evaluations, and constructions. After describing the centrality…

  16. Matriarchal Decision-Making.

    ERIC Educational Resources Information Center

    Warner, Linda Sue

    In contrast to European cultures, many American Indian societies have been matriarchal. Indian women have had a great deal of power, both as individuals and as groups, and have held various leadership roles within their tribes. Traditionally, Indian women have worked in partnership with men, and decision-making has been related to consensus…

  17. Decision Making in Educational Settings. Fastback 211.

    ERIC Educational Resources Information Center

    Sharman, Charles S.

    This booklet reviews decision-making, an important part of administrative processes, from the perspective of school teachers and other educators. The two most commonly used processes are the rational decision-making process (identify the problem, evaluate the problem, collect information, identify alternative solutions, select and implement…

  18. Influence of framing on medical decision making

    PubMed Central

    Gong, Jingjing; Zhang, Yan; Feng, Jun; Huang, Yonghua; Wei, Yazhou; Zhang, Weiwei

    2013-01-01

    Numerous studies have demonstrated the robustness of the framing effect in a variety of contexts, especially in medical decision making. Unfortunately, research is still inconsistent as to how so many variables impact framing effects in medical decision making. Additionally, much attention should be paid to the framing effect not only in hypothetical scenarios but also in clinical experience. PMID:27034630

  19. 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.

  20. The transition to clinical expert: enhanced decision making for children aged less than 5 years attending the paediatric ED with acute respiratory conditions

    PubMed Central

    Bowen, Leah; Shaw, Alison; Lyttle, Mark D; Purdy, Sarah

    2017-01-01

    Background Rates of unplanned paediatric admissions are persistently high. Many admissions are short-stay events, lasting less than 48 hours. Objective This qualitative research explores factors that influence clinical decision making in the paediatric ED (PED) for children under 5 attending with acute respiratory conditions, focusing on how management decisions adapt with increasing experience. Method Semi-structured interviews were conducted with 15 PED clinicians (doctors, emergency nurse practitioners and registered nurses) with varying levels of experience in paediatric emergency medicine (PEM), emergency medicine or paediatrics. Audio-recorded interviews were transcribed and analysed thematically. Results There were clear differences in decision-making approaches between experienced clinicians and junior staff. The latter were more risk adverse, relying heavily on guidelines, set admission criteria, clinical theory and second opinions. This was particularly true for doctors. ‘Informal’ learning was apparent in accounts from less-experienced doctors and nurses, whereby tacit knowledge and risk management played an increasing role in the development of clinical intuition that permitted rapid assessment and treatment of young patients. Conclusions The emergence of intuition entwined with approaches to risk management and the role of these skills in clinical decision making, carry implications for the development of training programmes for clinicians working in PEM. Enhanced training for such groups to permit development of the supplementary skills described in this study could have the ability to improve care delivery and even reduce paediatric admissions. PMID:27496899

  1. “How are patient characteristics relevant for physicians' clinical decision making in diabetes?: An analysis of qualitative results from a cross-national factorial experiment”

    PubMed Central

    Campbell, Stephen M; Renfrew, Megan R; Marceau, Lisa D; Roland, Martin; McKinlay, John B

    2008-01-01

    Variations in medical practice have been widely documented and are a linchpin in explanations of health disparities. Evidence shows that clinical decision making varies according to patient, provider and health system characteristics. However, less is known about the processes underlying these aggregate associations and how physicians interpret various patient attributes. Verbal protocol analysis (otherwise known as ‘think-aloud’) techniques were used to analyze open-ended data from 244 physicians to examine which patient characteristics physicians identify as relevant for their decision making. Data are from a vignette-based factorial experiment measuring the effects of: (a) patient attributes (age, gender, race and socioeconomic status); (b) physician characteristics (gender and years of clinical experience); and (c) features of the healthcare system in two countries (USA, United Kingdom) on clinical decision making for diabetes. We find that physicians used patients’ demographic characteristics only as a starting point in their assessments, and proceeded to make detailed assessments about cognitive ability, motivation, social support and other factors they consider predictive of adherence with medical recommendations and therefore relevant to treatment decisions. These non-medical characteristics of patients were mentioned with much greater consistency than traditional biophysiologic markers of risk such as race, gender, and age. Types of explanations identified varied somewhat according to patient characteristics and to the country in which the interview took place. Results show that basic demographic characteristics are inadequate to the task of capturing information physicians draw from doctor-patient encounters, and that in order to fully understand differential clinical decision making there is a need to move beyond documentation of aggregate associations and further explore the mental and social processes at work. PMID:18703267

  2. Personalised Medicine Possible With Real-Time Integration of Genomic and Clinical Data To Inform Clinical Decision-Making.

    PubMed

    Martin-Sanchez, Fernando; Turner, Maureen; Johnstone, Alice; Heffer, Leon; Rafael, Naomi; Bakker, Tim; Thorne, Natalie; Macciocca, Ivan; Gaff, Clara

    2015-01-01

    Despite widespread use of genomic sequencing in research, there are gaps in our understanding of the performance and provision of genomic sequencing in clinical practice. The Melbourne Genomics Health Alliance (the Alliance), has been established to determine the feasibility, performance and impact of using genomic sequencing as a diagnostic tool. The Alliance has partnered with BioGrid Australia to enable the linkage of genomic sequencing, clinical treatment and outcome data for this project. This integrated dataset of genetic, clinical and patient sourced information will be used by the Alliance to evaluate the potential diagnostic value of genomic sequencing in routine clinical practice. This project will allow the Alliance to provide recommendations to facilitate the integration of genomic sequencing into clinical practice to enable personalised disease treatment.

  3. HER2 Testing and Clinical Decision Making in Gastroesophageal Adenocarcinoma: Guideline From the College of American Pathologists, American Society for Clinical Pathology, and American Society of Clinical Oncology.

    PubMed

    Bartley, Angela N; Washington, Mary Kay; Ventura, Christina B; Ismaila, Nofisat; Colasacco, Carol; Benson, Al B; Carrato, Alfredo; Gulley, Margaret L; Jain, Dhanpat; Kakar, Sanjay; Mackay, Helen J; Streutker, Catherine; Tang, Laura; Troxell, Megan; Ajani, Jaffer A

    2016-12-01

    ERBB2 (erb-b2 receptor tyrosine kinase 2 or HER2) is currently the only biomarker established for selection of a specific therapy for patients with advanced gastroesophageal adenocarcinoma (GEA). However, there are no comprehensive guidelines for the assessment of HER2 in patients with GEA. To establish an evidence-based guideline for HER2 testing in patients with GEA, to formalize the algorithms for methods to improve the accuracy of HER2 testing while addressing which patients and tumor specimens are appropriate, and to provide guidance on clinical decision making. The College of American Pathologists, American Society for Clinical Pathology, and American Society of Clinical Oncology convened an expert panel to conduct a systematic review of the literature to develop an evidence-based guideline with recommendations for optimal HER2 testing in patients with GEA. The panel is proposing 11 recommendations with strong agreement from the open-comment participants. The panel recommends that tumor specimen(s) from all patients with advanced GEA, who are candidates for HER2-targeted therapy, should be assessed for HER2 status before the initiation of HER2-targeted therapy. Clinicians should offer combination chemotherapy and a HER2-targeted agent as initial therapy for all patients with HER2-positive advanced GEA. For pathologists, guidance is provided for morphologic selection of neoplastic tissue, testing algorithms, scoring methods, interpretation and reporting of results, and laboratory quality assurance. This guideline provides specific recommendations for assessment of HER2 in patients with advanced GEA while addressing pertinent technical issues and clinical implications of the results. © 2016 College of American Pathologists, American Society for Clinical Pathology, and the American Society of Clinical Oncology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

  4. 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.

  5. Distributed Decision Making Environment.

    DTIC Science & Technology

    1982-12-01

    of a DDM Testbed 69 4.3.2 Design of Experiments on Distributed 71 Mission Planning 5. AUTOMATED DECISION MAKING TECHNIQUES 76 5.1 SEQUENTIAL...missile assignment scenario. A sequential assignment algorithm has been fully computer implemented and preliminary experiments with it have been run. An...implementation of a distributed version in which several humans can participate in experiments simultaneously. The distributed version will allow L1 us to

  6. Routine Outcome Monitoring and Clinical Decision-Making in Forensic Psychiatry Based on the Instrument for Forensic Treatment Evaluation.

    PubMed

    van der Veeken, Frida C A; Lucieer, Jacques; Bogaerts, Stefan

    2016-01-01

    Rehabilitation in forensic psychiatry is achieved gradually with different leave modules, in line with the Risk Need Responsivity model. A forensic routine outcome monitoring tool should measure treatment progress based on the rehabilitation theory, and it should be predictive of important treatment outcomes in order to be usable in decision-making. Therefore, this study assesses the predictive validity for both positive (i.e., leave) and negative (i.e., inpatient incidents) treatment outcomes with the Instrument for Forensic Treatment Evaluation (IFTE). Two-hundred and twenty-four patients were included in this study. ROC analyses were conducted with the IFTE factors and items for three leave modules: guided, unguided and transmural leave for the whole group of patients. Predictive validity of the IFTE for aggression in general, physical aggression specifically, and urine drug screening (UDS) violations was assessed for patients with the main diagnoses in Dutch forensic psychiatry, patients with personality disorders and the most frequently occurring co-morbid disorders: those with combined personality and substance use disorders. Results tentatively imply that the IFTE has a reasonable to good predictive validity for inpatient aggression and a marginal to reasonable predictive value for leave approvals and UDS violations. The IFTE can be used for information purposes in treatment decision-making, but reports should be interpreted with care and acknowledge patients' personal risk factors, strengths and other information sources.

  7. Decision-making about tamoxifen in women at high risk for breast cancer: clinical and psychological factors.

    PubMed

    Bober, Sharon L; Hoke, Lizbeth A; Duda, Rosemary B; Regan, Meredith M; Tung, Nadine M

    2004-12-15

    To explore the health-related and psychological factors that influence decision making about tamoxifen (Nolvadex; AstraZeneca, Waltham, MA) chemoprevention in women at increased risk for developing breast cancer. This study involves the assessment of 129 women eligible to take tamoxifen following cancer-risk counseling. Treatment decision and decision satisfaction were measured at 2 and 4 months following counseling. Health-related factors included physician recommendation, personal and family-related health history, and concern about side effects. Psychological factors included breast cancer-related anxiety, risk perception, and depression. At 2 months' follow-up, 44% of participants declined tamoxifen treatment. This number increased to 49% at 4 months. Personal and family health history were not related to the decision, but history of abnormal biopsy did predict tamoxifen use. Physician recommendation was highly correlated with treatment decision. Concern about side effects was related to the decision to decline treatment. Breast cancer-related anxiety and heightened risk perception were associated with the decision to take tamoxifen. However, anxiety and psychological distress were also negatively related to treatment satisfaction. Decision-making about tamoxifen is complex, and many eligible women decline treatment or remain undecided. Findings call for further educational follow-up with high-risk women after they undergo initial counseling. Factors related to misperceptions of risk and side effects, as well as psychological distress, may be particularly important targets for intervention.

  8. Routine Outcome Monitoring and Clinical Decision-Making in Forensic Psychiatry Based on the Instrument for Forensic Treatment Evaluation

    PubMed Central

    van der Veeken, Frida C. A.

    2016-01-01

    Background Rehabilitation in forensic psychiatry is achieved gradually with different leave modules, in line with the Risk Need Responsivity model. A forensic routine outcome monitoring tool should measure treatment progress based on the rehabilitation theory, and it should be predictive of important treatment outcomes in order to be usable in decision-making. Therefore, this study assesses the predictive validity for both positive (i.e., leave) and negative (i.e., inpatient incidents) treatment outcomes with the Instrument for Forensic Treatment Evaluation (IFTE). Methods Two-hundred and twenty-four patients were included in this study. ROC analyses were conducted with the IFTE factors and items for three leave modules: guided, unguided and transmural leave for the whole group of patients. Predictive validity of the IFTE for aggression in general, physical aggression specifically, and urine drug screening (UDS) violations was assessed for patients with the main diagnoses in Dutch forensic psychiatry, patients with personality disorders and the most frequently occurring co-morbid disorders: those with combined personality and substance use disorders. Results and Conclusions Results tentatively imply that the IFTE has a reasonable to good predictive validity for inpatient aggression and a marginal to reasonable predictive value for leave approvals and UDS violations. The IFTE can be used for information purposes in treatment decision-making, but reports should be interpreted with care and acknowledge patients’ personal risk factors, strengths and other information sources. PMID:27517721

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

    PubMed

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

    2011-11-01

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

  10. To what extent psychiatric patients feel involved in decision making about their mental health care? Relationships with socio-demographic, clinical, and psychological variables.

    PubMed

    De las Cuevas, Carlos; Peñate, Wenceslao

    2014-12-01

    Shared decision making (SDM) is an essential component of patient-centered care, but there is little information about its use in the psychiatric care. To measure to what extent psychiatric patients feel they were involved in the process and steps of decision making about treatment choice and to analyse the influence of socio-demographic, clinical, and psychological processes on this perception. Cross-sectional survey involving 1100 consecutive psychiatric outpatients invited to complete the nine-item Shared Decision-Making Questionnaire (SDM-Q-9), health locus of control and control preferences, self-efficacy and drug attitude scales, as well as a questionnaire including socio-demographic and clinical variables. A high response rate of 77% was registered, resulting in a sample of 846 psychiatric outpatients. SDM-Q-9 total score indicate a moderately low degree of perceived participation, with differing perceived implementation of the individual the SDM process steps. Patient diagnosis evidenced significant differences in SDM perception. Patients' perception of SDM was explained by four main variables: the older the patient, the lower self-reported SDM; having a diagnosis of schizophrenia increases the likelihood of lower SDM; a positive attitude towards psychiatric drugs favors greater SDM, as well as a higher level of self-efficacy. The result of this study suggests that SDM is currently not widely practiced in psychiatric care. Further research is needed to examine if the low level of participation self-reported is justified by psychiatric patients' decisional capacity.

  11. HER2 Testing and Clinical Decision Making in Gastroesophageal Adenocarcinoma: Guideline From the College of American Pathologists, American Society for Clinical Pathology, and American Society of Clinical Oncology.

    PubMed

    Bartley, Angela N; Washington, Mary Kay; Ventura, Christina B; Ismaila, Nofisat; Colasacco, Carol; Benson, Al B; Carrato, Alfredo; Gulley, Margaret L; Jain, Dhanpat; Kakar, Sanjay; Mackay, Helen J; Streutker, Catherine; Tang, Laura; Troxell, Megan; Ajani, Jaffer A

    2016-12-01

    - ERBB2 (erb-b2 receptor tyrosine kinase 2 or HER2) is currently the only biomarker established for selection of a specific therapy for patients with advanced gastroesophageal adenocarcinoma (GEA). However, there are no comprehensive guidelines for the assessment of HER2 in patients with GEA. - To establish an evidence-based guideline for HER2 testing in patients with GEA, to formalize the algorithms for methods to improve the accuracy of HER2 testing while addressing which patients and tumor specimens are appropriate, and to provide guidance on clinical decision making. - The College of American Pathologists, American Society for Clinical Pathology, and American Society of Clinical Oncology convened an expert panel to conduct a systematic review of the literature to develop an evidence-based guideline with recommendations for optimal HER2 testing in patients with GEA. - The panel is proposing 11 recommendations with strong agreement from the open-comment participants. - The panel recommends that tumor specimen(s) from all patients with advanced GEA, who are candidates for HER2-targeted therapy, should be assessed for HER2 status before the initiation of HER2-targeted therapy. Clinicians should offer combination chemotherapy and a HER2-targeted agent as initial therapy for all patients with HER2-positive advanced GEA. For pathologists, guidance is provided for morphologic selection of neoplastic tissue, testing algorithms, scoring methods, interpretation and reporting of results, and laboratory quality assurance. - This guideline provides specific recommendations for assessment of HER2 in patients with advanced GEA while addressing pertinent technical issues and clinical implications of the results.

  12. 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

  13. Moral agency as enacted justice: a clinical and ethical decision-making framework for responding to health inequities and social injustice.

    PubMed

    Edwards, Ian; Delany, Clare M; Townsend, Anne F; Swisher, Laura Lee

    2011-11-01

    This is the second of 2 companion articles in this issue. The first article explored the clinical and ethical implications of new emphases in physical therapy codes of conduct reflecting the growing evidence regarding the importance of social determinants of health, epidemiological trends for health service delivery, and the enhanced participation of physical therapists in shaping health care reform in a number of international contexts. The first article was theoretically oriented and proposed that a re-thinking of ethical frameworks expressed in codes of ethics could both inform and underpin practical strategies for working in primary health care. A review of the ethical principle of "justice," which, arguably, remains the least consensually understood and developed principle in the ethics literature of physical therapy, was provided, and a more recent perspective-the capability approach to justice-was discussed. The current article proposes a clinical and ethical decision-making framework, the ethical reasoning bridge (ER bridge), which can be used to assist physical therapy practitioners to: (1) understand and implement the capability approach to justice at a clinical level; (2) reflect on and evaluate both the fairness and influence of beliefs, perspectives, and context affecting health and disability through a process of "wide reflective equilibrium" and assist patients to do this as well; and (3) nurture the development of moral agency, in partnership with patients, through a transformative learning process manifest in a mutual "crossing" and "re-crossing" of the ER bridge. It is proposed that the development and exercise of moral agency represent an enacted justice that is the result of a shared reasoning and learning experience on the part of both therapists and patients.

  14. Cognitive elements in clinical decision-making: toward a cognitive model for medical education and understanding clinical reasoning.

    PubMed

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

    2010-05-01

    Physician cognition, metacognition and affect may have an impact upon the quality of clinical reasoning. The purpose of this study was to examine the relationship between measures of physician metacognition and affect and patient outcomes in obstetric practice. Reflective coping (RC), proactive coping, need for cognition (NFC), tolerance for ambiguity, state-trait anxiety and metacognitive awareness were assessed for obstetricians (n = 12) who provided intra-partum care to 4,149 women. Outcome measures included delivery mode and intrapartum asphyxia. Analysis was carried out using logistic regression and tree-based classification. Obstetricians with high RC scores were more likely to perform a caesarean section (OR 1.59, p < 0.0001), less likely undertake a mid-forceps or low forceps delivery (OR 0.41, p < 0.0001; OR 0.49, p < 0.0001), and more likely to supervise a spontaneous vaginal delivery (OR 1.17, p = 0.08). Obstetricians with high NFC scores were more likely to perform a caesarean section (OR 1.53, p = 0.03), more likely to undertake a vacuum delivery (OR 5.8, p = 0.001), less likely undertake a mid-forceps delivery (OR 0.45, p = 0.02) and less likely to supervise a spontaneous vaginal delivery (OR 0.47, p < 0.0001). Obstetricians high in trait anxiety were more likely to perform a mid forceps delivery (OR 2.49, p = 0.01) or a vacuum delivery (OR 5.08, p = 0.003), and less likely to supervise a spontaneous vaginal delivery (OR 0.38, p < 0.0001). NFC was negatively associated (OR 0.10, p < 0.001) and trait anxiety was positively associated with intrapartum asphyxia (p < 0.05, rho = 0.582). In summary, physician cognitive processes and affect have a significant impact on patient outcomes, particularly in situations where there is a higher level of clinical unpredictability.

  15. Clinical decision-making about inpatient violence risk at admission to a public-sector acute psychiatric hospital.

    PubMed

    Newton, Virginia M; Elbogen, Eric B; Brown, Carrie L; Snyder, Jennifer; Barrick, Ann Louise

    2012-01-01

    This is an examination of the extent to which patients who are violent in the hospital can be distinguished from nonviolent patients, based on information that is readily available at the time of admission to a state acute psychiatric hospital. The charts of 235 inpatients were examined retrospectively, by selecting 103 patients who had engaged in inpatient violence and comparing them with 132 randomly selected patients who had not during the same period. Data were gathered from initial psychiatric assessment and admissions face sheets in patients' charts, reflecting information available to a mental health professional within the first 24 hours of a patient's admission. Multivariate analysis showed that violent and nonviolent patients were distinguished by diagnosis, age, gender, estimated intelligence, psychiatric history, employment history, living situation, and agitated behavior. These factors led to an 80 percent correct classification of violent patients and thus may assist clinicians to structure decision-making about the risk of inpatient violence.

  16. The anatomy of clinical decision-making in multidisciplinary cancer meetings: A cross-sectional observational study of teams in a natural context.

    PubMed

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

    2016-06-01

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

  17. Teacher Participation in School Decision-Making.

    ERIC Educational Resources Information Center

    Razzell, Arthur

    1979-01-01

    Based partly on his experience at Ravenscote County Middle School, the author illustrates the increasing inappropriateness and indefensibility of headteacher autocracy and the dividends to be reaped from full staff participation in decision making. (Editor)

  18. Ethical Behavior & Decision-Making among Graduate Students

    ERIC Educational Resources Information Center

    French, Jennifer A.

    2012-01-01

    One-hundred and eleven graduate students enrolled in a clinical psychology training program (PsyD) participated in a research study that examined the ethical decision-making processes and factors that have been proposed to influence behavior (Smith, McGuire, Abbott, & Blau, 1991). Using a two-part questionnaire, data regarding the ethical…

  19. 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.

  20. A model for emergency department end-of-life communications after acute devastating events--part I: decision-making capacity, surrogates, and advance directives.

    PubMed

    Limehouse, Walter E; Feeser, V Ramana; Bookman, Kelly J; Derse, Arthur

    2012-09-01

    Making decisions for a patient affected by sudden devastating illness or injury traumatizes a patient's family and loved ones. Even in the absence of an emergency, surrogates making end-of-life treatment decisions may experience negative emotional effects. Helping surrogates with these end-of-life decisions under emergent conditions requires the emergency physician (EP) to be clear, making medical recommendations with sensitivity. This model for emergency department (ED) end-of-life communications after acute devastating events comprises the following steps: 1) determine the patient's decision-making capacity; 2) identify the legal surrogate; 3) elicit patient values as expressed in completed advance directives; 4) determine patient/surrogate understanding of the life-limiting event and expectant treatment goals; 5) convey physician understanding of the event, including prognosis, treatment options, and recommendation; 6) share decisions regarding withdrawing or withholding of resuscitative efforts, using available resources and considering options for organ donation; and 7) revise treatment goals as needed. Emergency physicians should break bad news compassionately, yet sufficiently, so that surrogate and family understand both the gravity of the situation and the lack of long-term benefit of continued life-sustaining interventions. EPs should also help the surrogate and family understand that palliative care addresses comfort needs of the patient including adequate treatment for pain, dyspnea, or anxiety. Part I of this communications model reviews determination of decision-making capacity, surrogacy laws, and advance directives, including legal definitions and application of these steps; Part II (which will appear in a future issue of AEM) covers communication moving from resuscitative to end-of-life and palliative treatment. EPs should recognize acute devastating illness or injuries, when appropriate, as opportunities to initiate end-of-life discussions and to

  1. Decision making in neonatologia.

    PubMed

    Paterlini, G; Tagliabue, P

    2010-06-01

    The field of neonatology presents a fascinating context in which hugely important decisions have to be made on the basis of physicians' assessments of the long term consequences of various possible choices. In many cases such assessments cannot be derived from a consensual professional opinion; the situation is characterized by a high level of uncertainty. A sample of neonatologists in different countries received a questionnaire including vignette cases for which no clear consensus exists regarding the (probabilistic) prognosis. They were asked to (I) assess the probability of various outcomes (death, severe impairment) and (II) choose a treatment to be offered to the parents. Information on the physicians' professional and socio-demographic characteristics and their ethical "values" was also collected. The goal of this international survey is to understand the prognosis and to analyze decision making by professionals in the context of life and death in medicine. The availability of an identical technology in different social and institutional contexts should help identifying the convergences and differences under consideration. Seventy percent of those invited responded to the questionnaire (International 60-80%). Italian neonatologists seem to be quite pessimistic about the prognosis of infants at high risk of death or long term disabilities, they show a pro-life attitude, but in a certain proportion are willing to change their minds if requested by parents. Furthermore personal opinions predominate in the decision-making process and the contribution of team meeting and/or ethic consultation seem not significantly modify the decisions.

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

    PubMed

    Malerba, Kirsten Hawkins; Tecklin, Jan Stephen

    2013-06-01

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

  3. Neural Basis of Strategic Decision Making.

    PubMed

    Lee, Daeyeol; Seo, Hyojung

    2016-01-01

    Human choice behaviors during social interactions often deviate from the predictions of game theory. This might arise partly from the limitations in the cognitive abilities necessary for recursive reasoning about the behaviors of others. In addition, during iterative social interactions, choices might change dynamically as knowledge about the intentions of others and estimates for choice outcomes are incrementally updated via reinforcement learning. Some of the brain circuits utilized during social decision making might be general-purpose and contribute to isomorphic individual and social decision making. By contrast, regions in the medial prefrontal cortex (mPFC) and temporal parietal junction (TPJ) might be recruited for cognitive processes unique to social decision making.

  4. Health-related quality of life assessment and reported outcomes in leukaemia randomised controlled trials - a systematic review to evaluate the added value in supporting clinical decision making.

    PubMed

    Efficace, Fabio; Kemmler, Georg; Vignetti, Marco; Mandelli, Franco; Molica, Stefano; Holzner, Bernhard

    2008-07-01

    Health-related quality of life (HRQOL) is increasingly reported as an important outcome in cancer clinical trials. However, very little evidence exists on the impact of such evaluation in randomised controlled trials (RCTs) of leukaemia patients. A systematic search of the literature from 1980 to 2007 was undertaken and studies were identified and evaluated independently, according to a pre-defined coding scheme, by three reviewers. Both HRQOL outcomes and traditional clinical reported outcomes were systematically analysed to evaluate their consistency and their relevance for supporting clinical decision making. Nine RCTs were identified, involving 3838 patients overall. There were four RCTs involving acute myeloid leukaemia patients (AML), three with chronic myeloid leukaemia (CML) and two with chronic lymphocytic leukaemia (CLL). Six studies were published after 2000 and provided fairly robust methodological quality. Imatinib greatly improved HRQOL compared to interferon based treatments in CML patients and fludarabine plus cyclophosphamide does not seem to have a deleterious impact on patient's HRQOL when compared to fludarabine alone or chlorambucil in CLL patients. This study revealed the paucity of HRQOL research in leukaemia patients. Nonetheless, HRQOL assessment is feasible in RCTs and has the great potential of providing valuable outcomes to further support clinical decision making.

  5. A Temporal Mining Framework for Classifying Un-Evenly Spaced Clinical Data: An Approach for Building Effective Clinical Decision-Making System.

    PubMed

    Jane, Nancy Yesudhas; Nehemiah, Khanna Harichandran; Arputharaj, Kannan

    2016-01-01

    Clinical time-series data acquired from electronic health records (EHR) are liable to temporal complexities such as irregular observations, missing values and time constrained attributes that make the knowledge discovery process challenging. This paper presents a temporal rough set induced neuro-fuzzy (TRiNF) mining framework that handles these complexities and builds an effective clinical decision-making system. TRiNF provides two functionalities namely temporal data acquisition (TDA) and temporal classification. In TDA, a time-series forecasting model is constructed by adopting an improved double exponential smoothing method. The forecasting model is used in missing value imputation and temporal pattern extraction. The relevant attributes are selected using a temporal pattern based rough set approach. In temporal classification, a classification model is built with the selected attributes using a temporal pattern induced neuro-fuzzy classifier. For experimentation, this work uses two clinical time series dataset of hepatitis and thrombosis patients. The experimental result shows that with the proposed TRiNF framework, there is a significant reduction in the error rate, thereby obtaining the classification accuracy on an average of 92.59% for hepatitis and 91.69% for thrombosis dataset. The obtained classification results prove the efficiency of the proposed framework in terms of its improved classification accuracy.

  6. Effectiveness of clinical practice guideline implementation on lower third molar management in improving clinical decision-making: a randomized controlled trial.

    PubMed

    van der Sanden, Wil J M; Mettes, Dirk G; Plasschaert, Alphons J M; Grol, Richard P T M; Mulder, Jan; Verdonschot, Emiel H

    2005-10-01

    The objective of this study was twofold, namely to evaluate the effectiveness of a dental clinical practice guideline on the management of asymptomatic impacted lower third molars (i) on referral rates and (ii) on dentists' change in knowledge. A two-arm cluster randomized controlled trial, with pre- and post-test assessments, was conducted. A guideline was implemented by multifaceted interventions (i.e. feedback, reminders, and an interactive meeting). The effect was evaluated after 1 yr by repeating the baseline questionnaire and by monitoring the number of patients who were referred for removal of their asymptomatic impacted mandibular third molars. Instruments were questionnaires for detecting changes in knowledge, patient records, and panoramic radiographs. The knowledge of dentists regarding asymptomatic mandibular third molar management was found to increase significantly in the intervention group as compared to the control group. There was no statistically significant difference between the groups in guideline-consistent patient referral rates at the post-test assessment. It was concluded that the methodology employed for dissemination and implementation of a clinical practice guideline on asymptomatic mandibular third molar management improves dentists' knowledge on this topic and is effective in improving decision-making in simulated cases; however, no clinical effect was demonstrated.

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

    PubMed

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

    2015-01-01

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

  8. [Treatment Decision-Making Process of Cancer Patients].

    PubMed

    Lee, Shiu-Yu C Katie

    2016-10-01

    The decision-making process that is used by cancer patients to determine their treatment has become more multi-foci, difficult and complicated in recent years. This has in part been attributed to the increasing incidence rate of cancer in Taiwan and the rapid development of medical technologies and treatment modalities. Oncology nurses must assist patients and family to make informed and value-based treatment decisions. Decision-making is an information process that involves appraising one's own expectation and values based on his/her knowledge on cancer and treatment options. Because cancer treatment involves risks and uncertainties, and impacts quality of life, the treatment decision-making for cancer is often stressful, or even conflicting. This paper discusses the decision-making behaviors of cancer patients and the decisional conflict, participation, and informational needs that are involved in cancer treatment. The trend toward shared decision-making and decisional support will be also explored in order to facilitate the future development of appropriate clinical interventions and research.

  9. Decision Making and the Limits of Evidence

    PubMed Central

    Boyko, Matthew; Iancu, Daniela; Lesiuk, Howard; Dowlatshahi, Dar

    2015-01-01

    We report the case of a pregnant woman treated for acute ischemic stroke and review the literature on acute stroke treatment in pregnancy. To our knowledge, this is the first case reporting the successful use of intravenous tissue plasminogen activator and a stent retriever for acute stroke in pregnancy. We then use this case to consider the way medical knowledge is used in therapeutic decision making and argue that decision making necessarily extends beyond the limits of clinical trial evidence. PMID:27053984

  10. Decision making in family medicine

    PubMed Central

    Labrecque, Michel; Ratté, Stéphane; Frémont, Pierre; Cauchon, Michel; Ouellet, Jérôme; Hogg, William; McGowan, Jessie; Gagnon, Marie-Pierre; Njoya, Merlin; Légaré, France

    2013-01-01

    Abstract Objective To compare the ability of users of 2 medical search engines, InfoClinique and the Trip database, to provide correct answers to clinical questions and to explore the perceived effects of the tools on the clinical decision-making process. Design Randomized trial. Setting Three family medicine units of the family medicine program of the Faculty of Medicine at Laval University in Quebec city, Que. Participants Fifteen second-year family medicine residents. Intervention Residents generated 30 structured questions about therapy or preventive treatment (2 questions per resident) based on clinical encounters. Using an Internet platform designed for the trial, each resident answered 20 of these questions (their own 2, plus 18 of the questions formulated by other residents, selected randomly) before and after searching for information with 1 of the 2 search engines. For each question, 5 residents were randomly assigned to begin their search with InfoClinique and 5 with the Trip database. Main outcome measures The ability of residents to provide correct answers to clinical questions using the search engines, as determined by third-party evaluation. After answering each question, participants completed a questionnaire to assess their perception of the engine’s effect on the decision-making process in clinical practice. Results Of 300 possible pairs of answers (1 answer before and 1 after the initial search), 254 (85%) were produced by 14 residents. Of these, 132 (52%) and 122 (48%) pairs of answers concerned questions that had been assigned an initial search with InfoClinique and the Trip database, respectively. Both engines produced an important and similar absolute increase in the proportion of correct answers after searching (26% to 62% for InfoClinique, for an increase of 36%; 24% to 63% for the Trip database, for an increase of 39%; P = .68). For all 30 clinical questions, at least 1 resident produced the correct answer after searching with either

  11. The functional neuroanatomy of decision-making.

    PubMed

    Rosenbloom, Michael H; Schmahmann, Jeremy D; Price, Bruce H

    2012-01-01

    Decision-making is a complex executive function that draws on past experience, present goals, and anticipation of outcome, and which is influenced by prevailing and predicted emotional tone and cultural context. Functional imaging investigations and focal lesion studies identify the orbitofrontal, anterior cingulate, and dorsolateral prefrontal cortices as critical to decision-making. The authors review the connections of these prefrontal regions with the neocortex, limbic system, basal ganglia, and cerebellum, highlight current ideas regarding the cognitive processes of decision-making that these networks subserve, and present a novel integrated neuroanatomical model for decision-making. Finally, clinical relevance of this circuitry is illustrated through a discussion of frontotemporal dementia, traumatic brain injury, and sociopathy.

  12. [Decision Making and Electrodermal Activity].

    PubMed

    Kobayakawa, Mutsutaka

    2016-08-01

    Decision making is aided by emotions. Bodily responses, such as sweating, heartbeat, and visceral sensation, are used to monitor the emotional state during decision making. Because decision making in dairy life is complicated and cognitively demanding, these bodily signals are thought to facilitate the decision making process by assigning positive or negative values for each of the behavioral options. The sweat response in a decision making task is measured by skin conductance response (SCR). SCR in decision making is divided into two categories: anticipatory SCR is observed before making decisions, and reward/punishment SCR is observed after the outcome of the decision is perceived. Brain lesion studies in human revealed that the amygdala and ventromedial prefrontal cortex are important in decision making. Patients with lesinon in the amygdala exhibit neither the anticipatory nor reward/punishment SCRs, while patients with the ventromedial prefrontal lesions have deficits only in the anticipatory SCRs. Decision making tasks and SCR analysis have contributed to reveal the implicit aspects of decision making. Further research is necessary for clarifying the role of explicit process of decision making and its relationship with the implicit process.

  13. Ensuring Resident Competence: A Narrative Review of the Literature on Group Decision Making to Inform the Work of Clinical Competency Committees

    PubMed Central

    Hauer, Karen E.; Cate, Olle ten; Boscardin, Christy K.; Iobst, William; Holmboe, Eric S.; Chesluk, Benjamin; Baron, Robert B.; O'Sullivan, Patricia S.

    2016-01-01

    Background The expectation for graduate medical education programs to ensure that trainees are progressing toward competence for unsupervised practice prompted requirements for a committee to make decisions regarding residents' progress, termed a clinical competency committee (CCC). The literature on the composition of these committees and how they share information and render decisions can inform the work of CCCs by highlighting vulnerabilities and best practices. Objective We conducted a narrative review of the literature on group decision making that can help characterize the work of CCCs, including how they are populated and how they use information. Methods English language studies of group decision making in medical education, psychology, and organizational behavior were used. Results The results highlighted 2 major themes. Group member composition showcased the value placed on the complementarity of members' experience and lessons they had learned about performance review through their teaching and committee work. Group processes revealed strengths and limitations in groups' understanding of their work, leader role, and information-sharing procedures. Time pressure was a threat to the quality of group work. Conclusions Implications of the findings include the risks for committees that arise with homogeneous membership, limitations to available resident performance information, and processes that arise through experience rather than deriving from a well-articulated purpose of their work. Recommendations are presented to maximize the effectiveness of CCC processes, including their membership and access to, and interpretation of, information to yield evidence-based, well-reasoned judgments. PMID:27168881

  14. Limited role of culture conversion for decision-making in individual patient care and for advancing novel regimens to confirmatory clinical trials.

    PubMed

    Phillips, Patrick P J; Mendel, Carl M; Burger, Divan A; Crook, Angela M; Crook, Angela; Nunn, Andrew J; Dawson, Rodney; Diacon, Andreas H; Gillespie, Stephen H

    2016-02-04

    Despite recent increased clinical trials activity, no regimen has proved able to replace the standard 6-month regimen for drug-sensitive tuberculosis. Understanding the relationship between microbiological markers measured during treatment and long-term clinical outcomes is critical to evaluate their usefulness for decision-making for both individual patient care and for advancing novel regimens into time-consuming and expensive pivotal phase III trials. Using data from the randomized controlled phase III trial REMoxTB, we evaluated sputum-based markers of speed of clearance of bacilli: time to smear negative status; time to culture negative status on LJ or in MGIT; daily rate of change of log10(TTP) to day 56; and smear or culture results at weeks 6, 8 or 12; as individual- and trial-level surrogate endpoints for long-term clinical outcome. Time to culture negative status on LJ or in MGIT, time to smear negative status and daily rate of change in log10(TTP) were each independent predictors of clinical outcome, adjusted for treatment (p <0.001). However, discrimination between low and high risk patients, as measured by the c-statistic, was modest and not much higher than the reference model adjusted for BMI, history of smoking, HIV status, cavitation, gender and MGIT TTP. Culture conversion during treatment for tuberculosis, however measured, has only a limited role in decision-making for advancing regimens into phase III trials or in predicting the outcome of treatment for individual patients. REMoxTB ClinicalTrials.gov number: NCT00864383.

  15. Shared decision-making in medication management: development of a training intervention.

    PubMed

    Stead, Ute; Morant, Nicola; Ramon, Shulamit

    2017-08-01

    Shared decision-making is a collaborative process in which clinicians and patients make treatment decisions together. Although it is considered essential to patient-centred care, the adoption of shared decision-making into routine clinical practice has been slow, and there is a need to increase implementation. This paper describes the development and delivery of a training intervention to promote shared decision-making in medication management in mental health as part of the Shared Involvement in Medication Management Education (ShIMME) project. Three stakeholder groups (service users, care coordinators and psychiatrists) received training in shared decision-making, and their feedback was evaluated. The programme was mostly well received, with all groups rating interaction with peers as the best aspect of the training. This small-scale pilot shows that it is feasible to deliver training in shared decision-making to several key stakeholders. Larger studies will be required to assess the effectiveness of such training.

  16. Decision making cognition in primary progressive aphasia.

    PubMed

    Gleichgerrcht, Ezequiel; Torralva, Teresa; Roca, María; Szenkman, Daniela; Ibanez, Agustin; Richly, Pablo; Pose, Mariángeles; Manes, Facundo

    2012-01-01

    We sought to investigate the decision making profile of Primary Progressive Aphasia (PPA) by assessing patients diagnosed with this disease (n = 10), patients diagnosed with behavioral variant frontotemporal dementia (bvFTD, n = 35), and matched controls (n = 14) using the Iowa Gambling Task, a widely used test that mimics real-life decision making. Participants were also evalu