Consultation sequencing of a hospital with multiple service points using genetic programming

NASA Astrophysics Data System (ADS)

Morikawa, Katsumi; Takahashi, Katsuhiko; Nagasawa, Keisuke

2018-07-01

A hospital with one consultation room operated by a physician and several examination rooms is investigated. Scheduled patients and walk-ins arrive at the hospital, each patient goes to the consultation room first, and some of them visit other service points before consulting the physician again. The objective function consists of the sum of three weighted average waiting times. The problem of sequencing patients for consultation is focused. To alleviate the stress of waiting, the consultation sequence is displayed. A dispatching rule is used to decide the sequence, and best rules are explored by genetic programming (GP). The simulation experiments indicate that the rules produced by GP can be reduced to simple permutations of queues, and the best permutation depends on the weight used in the objective function. This implies that a balanced allocation of waiting times can be achieved by ordering the priority among three queues.

Translating Evidence to Facilitate Shared Decision Making: Development and Usability of a Consult Decision Aid Prototype.

PubMed

Stacey, Dawn; Légaré, France; Lyddiatt, Anne; Giguere, Anik M C; Yoganathan, Manosila; Saarimaki, Anton; Pardo, Jordi Pardo; Rader, Tamara; Tugwell, Peter

2016-12-01

The purpose of this study was to translate evidence from Cochrane Reviews into a format that can be used to facilitate shared decision making during the consultation, namely patient decision aids. A systematic development process (a) established a stakeholder committee; (b) developed a prototype according to the International Patient Decision Aid Standards; (c) applied the prototype to a Cochrane Review and used an interview-guided survey to evaluate acceptability/usability; (d) created 12 consult decision aids; and (e) used a Delphi process to reach consensus on considerations for creating a consult decision aid. The 1-page prototype includes (a) a title specifying the decision; (b) information on the health condition, options, benefits/harms with probabilities; (c) an explicit values clarification exercise; and (d) questions to screen for decisional conflict. Hyperlinks provide additional information on definitions, probabilities presented graphically, and references. Fourteen Cochrane Consumer Network members and Cochrane Editorial Unit staff participated. Thirteen reported that it would help patient/clinician discussions and were willing to use and/or recommend it. Seven indicated the right amount of information, six not enough, and one too much. Changes to the prototype were more links to definitions, more white space, and details on GRADE evidence ratings. Creating 12 consult decision aids took about 4 h each. We identified ten considerations when selecting Cochrane Reviews for creating consult decision aids. Using a systematic process, we developed a consult decision aid prototype to be populated with evidence from Cochrane Reviews. It was acceptable and easy to apply. Future studies will evaluate implementation of consult decision aids.

Patients' experiences of communication and involvement in decision-making about atrial fibrillation treatment in consultations with nurses and physicians.

PubMed

Siouta, Eleni; Hellström Muhli, Ulla; Hedberg, Berith; Broström, Anders; Fossum, Bjöörn; Karlgren, Klas

2016-09-01

Insights in consultations across patient interactions with physicians and nurses are of vital importance for strengthening the patients' involvement in the treatment decision-making process. The experience of involvement and communication in decision-making from the patients' perspective has been sparsely explored. To examine how patients describe involvement in and communication about decision-making regarding treatment in consultations with nurses and physicians. Twenty-two patients with atrial fibrillation (AF), aged 37-90 years, were interviewed directly after their consultations with nurses and physicians in outpatient AF clinics in six Swedish hospitals. In consultations with nurses, the patients felt involved when obtaining clarifications about AF as a disease and its treatment and when preparing for and building up confidence in decision-making. In consultations with physicians, the patients felt involved when they could cooperate in decision-making, when acquiring knowledge, and when they felt that they were being understood. One shared category was found in consultations with both nurses and physicians, and the patients felt involved when they had a sense of trust and felt secure during and between consultations. Patients with AF stated that they would need to acquire knowledge and build up confidence and ability in order to be effectively involved in the decision-making about treatment. Despite not being actively involved in decision-making, patients felt involved through experiencing supportive and confirming communication. Attention must be given to the relationship with the patient to create the conditions for patient involvement in the consultation. This can be achieved through supportive communication attempting to create a feeling of clarity and building confidence. This will support involvement in decision-making concerning AF treatment and feelings of being understood and of trust in physicians and/or nurses. © 2015 Nordic College of Caring Science.

The assessment of depressive patients' involvement in decision making in audio-taped primary care consultations.

PubMed

Loh, Andreas; Simon, Daniela; Hennig, Katrin; Hennig, Benjamin; Härter, Martin; Elwyn, Glyn

2006-11-01

In primary care of depression treatment options such as antidepressants, counseling and psychotherapy are reasonable. Patient involvement could foster adherence and clinical outcome. However, there is a lack of empirical information about the extent to which general practitioners involve patients in decision making processes in this condition, and about the consultation time spent for distinct decision making tasks. Twenty general practice consultations with depressive patients prior to a treatment decision were audio-taped and transcribed. Patient involvement in decision making was assessed with the OPTION-scale and durations of decision making stages were measured. Mean duration of consultations was 16 min, 6s. The mean of the OPTION-items were between 0.0 and 26.9, in a scale range from 0 to 100. Overall, 78.6% of the consultation time was spent for the step "problem definition" (12 min, 42 s). Very low levels of patient involvement in medical decisions were observed in consultations about depression. Physicians used the majority of their time for the definition of the patient's medical problem. To improve treatment decision making in this condition, general practitioners should enhance their decision making competences and be more aware of the time spent in each decision making stage.

In re Estate of Longeway.

PubMed

1989-11-13

The guardian of an incompetent patient appealed a lower court's decision dismissing the guardian's petition to withdraw artificially administered nutrition and hydration from the patient. The Illinois Supreme Court ruled that the guardian could exercise the right to refuse artificial nutrition and hydration on behalf of the patient under certain conditions. The patient must be terminally ill and diagnosed as irreversibly comatose. The patient's attending physician and two other consulting physicians must concur in this diagnosis. Also, a court order is required for the guardian to withdraw life support. The court further ruled that specific express intent is helpful in determining whether to withdraw artificial sustenance, but it is not necessary for exercising the guardian's substituted judgement. The Illinois Supreme Court reversed the lower court's dismissal and remanded the case for further proceedings.

"What Should I Do?" How Consultants Impact Adolescents' Risky Decisions

ERIC Educational Resources Information Center

Finken, Laura

2009-01-01

Consultation plays a key role in adolescents' risky decisions and influences what options and consequences are considered, how potential consequences are valued, and even what choices adolescents make. Even with impulsive decisions, informal consultation affects how likely an adolescent is to engage in risky behaviors. Unfortunately several…

Lay Consultations in Heart Failure Symptom Evaluation.

PubMed

Reeder, Katherine M; Sims, Jessica L; Ercole, Patrick M; Shetty, Shivan S; Wallendorf, Michael

2017-01-01

Lay consultations can facilitate or impede healthcare. However, little is known about how lay consultations for symptom evaluation affect treatment decision-making. The purpose of this study was to explore the role of lay consultations in symptom evaluation prior to hospitalization among patients with heart failure. Semi-structured interviews were conducted with 60 patients hospitalized for acute decompensated heart failure. Chi-square and Fisher's exact tests, along with logistic regression were used to characterize lay consultations in this sample. A large proportion of patients engaged in lay consultations for symptom evaluation and decision-making before hospitalization. Lay consultants provided attributions and advice and helped make the decision to seek medical care. Men consulted more often with their spouse than women, while women more often consulted with adult children. Findings have implications for optimizing heart failure self-management interventions, improving outcomes, and reducing hospital readmissions.

Representation or reason: consulting the public on the ethics of health policy.

PubMed

Mullen, Caroline

2008-12-01

Consulting the public about the ethical approaches underlying health policies can seem an appealing means of addressing concerns about limited public participation in development of health policy. However ambiguity surrounds questions of whether, or how consultation can really contribute to more defensible decisions about ethical aspects of policy. This paper clarifies the role and limits of public consultation on ethics, beginning by separating different senses of defensibility in decisions on ethics. Defensibility of ethical decisions could be understood either in the sense of legitimacy in virtue of reflecting the opinions of the public whose interests are affected, or in the sense of being able to withstand and respond to challenges presented in ethical debate. The question then is whether there are forms of consultation which have the potential to realise more defensible decisions in either of these senses. Problems of adequately accounting for the views of those affected by policy decisions casts doubt on the plausibility of using consultation as a means of determining the opinions of the public. Consultation can have a role by bringing new ideas and challenges to debate, although it is uncertain whether this will increase the defensibility of any decision on ethics.

27 The DiPEP (Diagnosis of PE in Pregnancy) study: can clinical assessment, d-dimer or chest x-ray be used to select pregnant or postpartum women with suspected PE for diagnostic imaging?

PubMed

Goodacre, Steve; Horspool, Kimberley; Nelson-Piercy, Catherine; Knight, Marian; Shephard, Neil; Lecky, Fiona; Thomas, Steven; Hunt, Beverley; Fuller, Gordon

2017-12-01

To determine whether clinical features (in the form of a clinical decision rule) or d-dimer can be used to select pregnant or postpartum women with suspected PE for diagnostic imaging. Observational cohort study augmented with additional cases. Consultant-led maternity units participating in the UK Obstetric Surveillance System (UKOSS) and emergency departments and maternity units at eleven prospectively recruiting sites. 198 pregnant or postpartum women with diagnosed PE identified through UKOSS and 324 pregnant or postpartum women with suspected PE from prospectively recruiting sites. Data were collected relating to clinical features, elements of clinical decision rules, d-dimer measurements, diagnostic imaging, treatment for PE and adverse outcomes. Women were classified as having or not having PE on the basis of diagnostic imaging, treatment and subsequent adverse outcomes. Primary analysis was limited to women with conclusive diagnostic imaging. Secondary analyses included women with clinically diagnosed or ruled out PE. The primary analysis included 181 women with PE and 259 without. Most clinical features showed no association with PE. The only exceptions were number of previous pregnancies over 24 weeks (p=0.017), no varicose veins (p=0.045), no recent long haul travel (p=0.006), recent surgery including caesarean section (p=0.001), increased temperature (p=0.003), low oxygen saturation (p<0.001), PE-related chest x-ray abnormality (p=0.01) and other chest x-ray abnormality (p=0.001).Clinical decision rules had areas under the receiver-operator characteristic curve ranging from 0.577 to 0.732. No clinically useful threshold for decision-making was identified for any rule. The sensitivities and specificities of d-dimer were 88.4% and 8.8% using the standard laboratory threshold and 69.8% and 32.8% using a pregnancy-specific threshold. Clinical decision rules, d-dimer and chest x-ray should not be used to select pregnant or postpartum women with suspected PE for diagnostic imaging. © 2017, Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Working with interpreters: The challenges of introducing Option Grid patient decision aids.

PubMed

Wood, Fiona; Phillips, Katie; Edwards, Adrian; Elwyn, Glyn

2017-03-01

We aimed to observe how an Option Grid™ decision aid for clinical encounters might be used where an interpreter is present, and to assess the impact of its use on shared decision making. Data were available from three clinical consultations between patient, clinician (a physiotherapist), and interpreter about knee osteoarthritis. Clinicians were trained in the use of an Option Grid decision aid and the tool was used. Consultations were audio-recorded, transcribed, and translated by independent translators into English. Analysis revealed the difficulties with introducing a written decision aid into an interpreted consultation. The extra discussion needed between the clinician and interpreter around the principles and purpose of shared decision making and instructions regarding the Option Grid decision aid proved challenging and difficult to manage. Discussion of treatment options while using an Option Grid decision aid was predominantly done between clinician and interpreter. The patient appeared to have little involvement in discussion of treatment options. Patients were not active participants within the discussion. Further work needs to be done on how shared decision making can be achieved within interpreted consultations. Option Grid decision aids are not being used as intended in interpreted consultations. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

A center for commercial development of space: Real-time satellite mapping. Remote sensing-based agricultural information expert system

NASA Technical Reports Server (NTRS)

Hadipriono, Fabian C.; Diaz, Carlos F.; Merritt, Earl S.

1989-01-01

The research project results in a powerful yet user friendly CROPCAST expert system for use by a client to determine the crop yield production of a certain crop field. The study is based on the facts that heuristic assessment and decision making in agriculture are significant and dominate much of agribusiness. Transfer of the expert knowledge concerning remote sensing based crop yield production into a specific expert system is the key program in this study. A knowledge base consisting of a root frame, CROP-YIELD-FORECAST, and four subframes, namely, SATELLITE, PLANT-PHYSIOLOGY, GROUND, and MODEL were developed to accommodate the production rules obtained from the domain expert. The expert system shell Personal Consultant Plus version 4.0. was used for this purpose. An external geographic program was integrated to the system. This project is the first part of a completely built expert system. The study reveals that much effort was given to the development of the rules. Such effort is inevitable if workable, efficient, and accurate rules are desired. Furthermore, abundant help statements and graphics were included. Internal and external display routines add to the visual capability of the system. The work results in a useful tool for the client for making decisions on crop yield production.

5 CFR 2426.2 - Requests; petition and procedures for determination of eligibility for national consultation rights.

Code of Federal Regulations, 2010 CFR

2010-01-01

... determination of eligibility for national consultation rights. 2426.2 Section 2426.2 Administrative Personnel... RELATIONS AUTHORITY NATIONAL CONSULTATION RIGHTS AND CONSULTATION RIGHTS ON GOVERNMENT-WIDE RULES OR REGULATIONS National Consultation Rights § 2426.2 Requests; petition and procedures for determination of...

Lay Consultations in Heart Failure Symptom Evaluation

PubMed Central

Reeder, Katherine M.; Sims, Jessica L.; Ercole, Patrick M.; Shetty, Shivan S.; Wallendorf, Michael

2017-01-01

Purpose Lay consultations can facilitate or impede healthcare. However, little is known about how lay consultations for symptom evaluation affect treatment decision-making. The purpose of this study was to explore the role of lay consultations in symptom evaluation prior to hospitalization among patients with heart failure. Methods Semi-structured interviews were conducted with 60 patients hospitalized for acute decompensated heart failure. Chi-square and Fisher’s exact tests, along with logistic regression were used to characterize lay consultations in this sample. Results A large proportion of patients engaged in lay consultations for symptom evaluation and decision-making before hospitalization. Lay consultants provided attributions and advice and helped make the decision to seek medical care. Men consulted more often with their spouse than women, while women more often consulted with adult children. Conclusions Findings have implications for optimizing heart failure self-management interventions, improving outcomes, and reducing hospital readmissions. PMID:29399657

Clinical decision making in dermatology: observation of consultations and the patients' perspectives.

PubMed

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

2010-01-01

Clinical decision making is a complex process and might be influenced by a wide range of clinical and non-clinical factors. Little is known about this process in dermatology. The aim of this study was to explore the different types of management decisions made in dermatology and to identify factors influencing those decisions from observation of consultations and interviews with the patients. 61 patient consultations were observed by a physician with experience in dermatology. The patients were interviewed immediately after each consultation. Consultations and interviews were audio recorded, transcribed and their content analysed using thematic content analysis. The most common management decisions made during the consultations included: follow-up, carrying out laboratory investigation, starting new topical treatment, renewal of systemic treatment, renewal of topical treatment, discharging patients and starting new systemic treatment. Common influences on those decisions included: clinical factors such as ineffectiveness of previous therapy, adherence to prescribing guidelines, side-effects of medications, previous experience with the treatment, deterioration or improvement in the skin condition, and chronicity of skin condition. Non-clinical factors included: patient's quality of life, patient's friends or relatives, patient's time commitment, travel or transportation difficulties, treatment-related costs, availability of consultant, and availability of treatment. The study has shown that patients are aware that management decisions in dermatology are influenced by a wide range of clinical and non-clinical factors. Education programmes should be developed to improve the quality of decision making. Copyright © 2010 S. Karger AG, Basel.

Medical communication and technology: a video-based process study of the use of decision aids in primary care consultations.

PubMed

Kaner, Eileen; Heaven, Ben; Rapley, Tim; Murtagh, Madeleine; Graham, Ruth; Thomson, Richard; May, Carl

2007-01-10

Much of the research on decision-making in health care has focused on consultation outcomes. Less is known about the process by which clinicians and patients come to a treatment decision. This study aimed to quantitatively describe the behaviour shown by doctors and patients during primary care consultations when three types of decision aids were used to promote treatment decision-making in a randomised controlled trial. A video-based study set in an efficacy trial which compared the use of paper-based guidelines (control) with two forms of computer-based decision aids (implicit and explicit versions of DARTS II). Treatment decision concerned warfarin anti-coagulation to reduce the risk of stroke in older patients with atrial fibrillation. Twenty nine consultations were video-recorded. A ten-minute 'slice' of the consultation was sampled for detailed content analysis using existing interaction analysis protocols for verbal behaviour and ethological techniques for non-verbal behaviour. Median consultation times (quartiles) differed significantly depending on the technology used. Paper-based guidelines took 21 (19-26) minutes to work through compared to 31 (16-41) minutes for the implicit tool; and 44 (39-55) minutes for the explicit tool. In the ten minutes immediately preceding the decision point, GPs dominated the conversation, accounting for 64% (58-66%) of all utterances and this trend was similar across all three arms of the trial. Information-giving was the most frequent activity for both GPs and patients, although GPs did this at twice the rate compared to patients and at higher rates in consultations involving computerised decision aids. GPs' language was highly technically focused and just 7% of their conversation was socio-emotional in content; this was half the socio-emotional content shown by patients (15%). However, frequent head nodding and a close mirroring in the direction of eye-gaze suggested that both parties were active participants in the conversation Irrespective of the arm of the trial, both patients' and GPs' behaviour showed that they were reciprocally engaged in these consultations. However, even in consultations aimed at promoting shared decision-making, GPs' were verbally dominant, and they worked primarily as information providers for patients. In addition, computer-based decision aids significantly prolonged the consultations, particularly the later phases. These data suggest that decision aids may not lead to more 'sharing' in treatment decision-making and that, in their current form, they may take too long to negotiate for use in routine primary care.

Considering patient values and treatment preferences enhances patient involvement in rectal cancer treatment decision making.

PubMed

Kunneman, Marleen; Marijnen, Corrie A M; Baas-Thijssen, Monique C M; van der Linden, Yvette M; Rozema, Tom; Muller, Karin; Geijsen, Elisabeth D; Stiggelbout, Anne M; Pieterse, Arwen H

2015-11-01

The shared decision making (SDM) model states that patients' values and preferences should be clarified to choose a strategy that best fits the patient. This study aimed to assess whether values and preferences of rectal cancer patients are voiced and considered in deciding about preoperative radiotherapy (PRT), and whether this makes patients feel more involved in treatment decision making. Pre-treatment consultations of radiation oncologists and patients eligible for PRT were audiotaped (N=90). Tapes were transcribed and coded to identify patients' values and treatment preferences. Patients filled in a post-consultation questionnaire on their perceived involvement in decision making (N=60). Patients' values were voiced for 62/611 of benefits/harms addressed (10%), in 38/90 consultations (42%; maximum 4 values per consultation), and most often related to major long-term treatment outcomes. Patients' treatment preferences were discussed in 20/90 consultations (22%). In 16/90 consultations (18%), the oncologists explicitly indicated to consider patients' values or preferences. Patients perceived a significantly more active role in decision making if their values or preferences had been voiced or considered. Patients' values and treatment preferences are voiced or considered in a minority of consultations. If they are, this increases patients' perceived involvement in the decision making process. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

The Role of Ethics Committees and Ethics Consultation in Allocation Decisions

PubMed Central

Strech, Daniel; Hurst, Samia; Danis, Marion

2013-01-01

Background Decisions about the allocation and rationing of medical interventions likely occur in all health care systems worldwide. So far very little attention has been given to the question of what role ethics consultation and ethics committees could or should play in questions of allocation at the hospital level. Objectives and Methods This article argues for the need for ethics consultation in rationing decisions using empirical data about the status quo and the inherent nature of bedside rationing. Subsequently, it introduces a 4-stage process for establishing and conducting ethics consultation in rationing questions with systematic reference to core elements of procedural justice. Results Qualitative and quantitative findings show a significant demand for ethics consultation expressed directly by doctors, as well as additional indirect evidence of such a need as indicated by ethically challenging circumstances of inconsistent and structurally disadvantaging rationing decisions. To address this need, we suggest 4 stages for establishing and conducting ethics consultation in rationing questions we recommend: (1) training, (2) identifying actual scarcity-related problems at clinics, (3) supporting decision-making, and (4) evaluation. Conclusion This process of ethics consultation regarding rationing decisions would facilitate the achievement of several practical goals: (i) encouragement of an awareness and understanding of ethical problems in bedside rationing, (ii) encouragement of achieving efficiency along with rationing, (iii) reinforcement of consistency in inter- and intraindvidual decision-making, (iv) encouragement of explicit reflection and justification of the prioritization criteria taken into consideration, (v) improvement in internal (in-house) and external transparency, and (vi) prevention of the misuse of the corresponding consulting structures. PMID:20706163

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

PubMed

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

2011-06-01

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

Why do people consult the doctor?

PubMed

Campbell, S M; Roland, M O

1996-02-01

Symptoms are an everyday part of most peoples' lives and many people with illness do not consult their doctor. The decision to consult is not based simply on the presence or absence of medical problems. Rather it is based on a complex mix of social and psychological factors. This literature review seeks to explore some of the pathways to care and those factors associated with low and high rates of consultation. The paper examines the impact of socioeconomic and demographic factors on consultation rates and, using a revised version of the Health Belief Model, it highlights the psychological factors which influence decisions to seek medical care. Barriers which can inhibit consultation are discussed, as the decision to seek care will only result in a consultation if there is adequate access to care. Whilst poor health status and social disadvantage increase both "objective" medical need and in turn, consultation rates, a range of other social and psychological factors have been shown to influence consulting behaviour.

22 CFR 401.21 - Consultation.

Code of Federal Regulations, 2010 CFR

2010-04-01

... 22 Foreign Relations 2 2010-04-01 2010-04-01 true Consultation. 401.21 Section 401.21 Foreign Relations INTERNATIONAL JOINT COMMISSION, UNITED STATES AND CANADA RULES OF PROCEDURE Applications § 401.21 Consultation. The Commission may meet or consult with the applicant, the Governments and other persons or their...

The use of Ethics Decision-Making Frameworks by Canadian Ethics Consultants: A Qualitative Study.

PubMed

Kaposy, Chris; Brunger, Fern; Maddalena, Victor; Singleton, Richard

2016-10-01

In this study, Canadian healthcare ethics consultants describe their use of ethics decision-making frameworks. Our research finds that ethics consultants in Canada use multi-purpose ethics decision-making frameworks, as well as targeted frameworks that focus on reaching an ethical resolution to a particular healthcare issue, such as adverse event reporting, or difficult triage scenarios. Several interviewees mention the influence that the accreditation process in Canadian healthcare organizations has on the adoption and use of such frameworks. Some of the ethics consultants we interviewed also report on their reluctance to use these tools. Limited empirical work has been done previously on the use of ethics decision-making frameworks. This study begins to fill this gap in our understanding of the work of healthcare ethics consultants. © 2016 John Wiley & Sons Ltd.

77 FR 467 - Notice of Tribal Consultation Meetings Regarding How the Current SACWIS Regulations Affect Tribes...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-01-05

... Administering a Title IV-E Program AGENCY: Children's Bureau, ACYF, ACF, HHS. ACTION: Notice of Tribal Consultation. SUMMARY: Title IV-E rules provide Federal Financial Participation (FFP) through a beneficial cost...-centric rules have on their ability to build and operate information systems that will support their title...

Consulting as a Strategy for Knowledge Transfer

PubMed Central

Jacobson, Nora; Butterill, Dale; Goering, Paula

2005-01-01

Academic researchers who work on health policy and health services are expected to transfer knowledge to decision makers. Decision makers often do not, however, regard academics’ traditional ways of doing research and disseminating their findings as relevant or useful. This article argues that consulting can be a strategy for transferring knowledge between researchers and decision makers and is effective at promoting the “enlightenment” and “interactive” models of knowledge use. Based on three case studies, it develops a model of knowledge transfer–focused consulting that consists of six stages and four types of work. Finally, the article explores how knowledge is generated in consulting and identifies several classes of factors facilitating its use by decision makers. PMID:15960773

The Effect of Screen-to-Screen Versus Face-to-Face Consultation on Doctor-Patient Communication: An Experimental Study with Simulated Patients

PubMed Central

Tates, Kiek; Kanters, Saskia; Nieboer, Theodoor E; Gerritse, Maria BE

2017-01-01

Background Despite the emergence of Web-based patient-provider contact, it is still unclear how the quality of Web-based doctor-patient interactions differs from face-to-face interactions. Objective This study aimed to examine (1) the impact of a consultation medium on doctors’ and patients’ communicative behavior in terms of information exchange, interpersonal relationship building, and shared decision making and (2) the mediating role of doctors’ and patients’ communicative behavior on satisfaction with both types of consultation medium. Methods Doctor-patient consultations on pelvic organ prolapse were simulated, both in a face-to-face and in a screen-to-screen (video) setting. Twelve medical interns and 6 simulated patients prepared 4 different written scenarios and were randomized to perform a total of 48 consultations. Effects of the consultations were measured by questionnaires that participants filled out directly after the consultation. Results With respect to patient-related outcomes, satisfaction, perceived information exchange, interpersonal relationship building, and perceived shared decision making showed no significant differences between face-to-face and screen-to-screen consultations. Patients’ attitude toward Web-based communication (b=−.249, P=.02 and patients’ perceived time and attention (b=.271, P=.03) significantly predicted patients’ perceived interpersonal relationship building. Patients’ perceived shared decision making was positively related to their satisfaction with the consultation (b=.254, P=.005). Overall, patients experienced significantly greater shared decision making with a female doctor (mean 4.21, SD 0.49) than with a male doctor (mean 3.66 [SD 0.73]; b=.401, P=.009). Doctor-related outcomes showed no significant differences in satisfaction, perceived information exchange, interpersonal relationship building, and perceived shared decision making between the conditions. There was a positive relationship between perceived information exchange and doctors’ satisfaction with the consultation (b=.533, P<.001). Furthermore, doctors’ perceived interpersonal relationship building was positively related to doctors’ satisfaction with the consultation (b=.331, P=.003). Conclusions In this study, the quality of doctor-patient communication, as indicated by information exchange, interpersonal relationship building, and shared decision making, did not differ significantly between Web-based and face-to-face consultations. Doctors and simulated patients were equally satisfied with both types of consultation medium, and no differences were found in the manner in which participants perceived communicative behavior during these consultations. The findings suggest that worries about a negative impact of Web-based video consultation on the quality of patient-provider consultations seem unwarranted as they offer the same interaction quality and satisfaction level as regular face-to-face consultations. PMID:29263017

Interdependence in decision-making by medical consultants: implications for improving the efficiency of inpatient physician services.

PubMed

Wilk, Adam S; Chen, Lena M

2017-12-01

Hospital administrators are seeking to improve efficiency in medical consultation services, yet whether consultants make decisions to provide more or less care is unknown. We examined how medical consultants account for prior consultants' care when determining whether to provide intensive consulting care or sign off in the treatment of complex surgical inpatients. We applied three distinct theoretical frameworks in the interpretation of our results. We performed a retrospective cohort study of consultants' care intensity, measured alternately using a dummy variable for providing two or more days consulting (versus one) and a continuous measure of total days consulting, with 100% Medicare claims data from 2007-2010. Our analytic samples included consults for beneficiaries undergoing coronary artery bypass grafting (n = 61,785) or colectomy (n = 33,460) in general acute care hospitals. We compared the care intensity of consultants who observed different patterns of consulting care before their initial consults using ordinary least squares regression models at the patient-physician dyad level, controlling for patient comorbidity and many other patient- and physician-level factors as well as hospital region and year fixed effects. Consultants were less likely to provide intensive consulting care with each additional prior consultant on the case (1.2-1.7 percent) or if a prior consultant rendered intensive consulting care (20.6-21.5 percent) but more likely when prior consults were more concentrated across consultants (2.9-3.1 percent). Effects on consultants' total days consulting were similar. On average, consultants appeared to calibrate their care intensity for individual patients to maximize their value to all patients. Interventions for improving consulting care efficiency should seek to facilitate (not constrain) consultants' decision-making processes.

The impact of DECISION+2 on patient intention to engage in shared decision making: secondary analysis of a multicentre clustered randomized trial.

PubMed

Couët, Nicolas; Labrecque, Michel; Robitaille, Hubert; Turcotte, Stéphane; Légaré, France

2015-12-01

Training health professionals in shared decision making (SDM) may influence their patients' intention to engage in SDM. To assess the impact of DECISION+2, a SDM training programme for family physicians about the use of antibiotics to treat acute respiratory infections (ARIs), on their patients' intention to engage in SDM in future consultations. Secondary analysis of a multicentre clustered randomized trial. Three hundred and fifty-nine patients consulting family physicians about an ARI in nine family practice teaching units (FPTUs). DECISION+2 (two-hour online tutorial, two-hour workshop, and decision support tools) was offered in the experimental group (five FPTUs, 162 physicians, 181 patients). Usual care was provided in the control group (four FPTUs, 108 physicians, 178 patients). Change in patients' intention scores (range -3 to +3) between pre- and post-consultation. The mean ± SD [median] scores of intention to engage in SDM were high in both study groups before consultation (DECISION+2 group: 1.4 ± 1.0 [1.7]; control group: 1.5 ± 1.1 [1.7]) and increased in both groups after consultation (DECISION+2 group: 2.1 ± 1.1 [2.7]; control group: 1.9 ± 1.2 [2.3]). Change of intention, classified as either increased, stable or decreased, was not statistically associated with the exposure to the DECISION+2 programme after adjusting for the cluster design (proportional odds ratio = 1.5; 95% confidence interval = 0.8-3.0). DECISION+2 had no significant impact on patients' intention to engage in SDM for choosing to use antibiotics or not to treat an ARI in future consultations. Patient-targeted interventions may be necessary to achieve this purpose. © 2014 John Wiley & Sons Ltd.

Shared decision-making in pediatric otolaryngology: Parent, physician and observational perspectives.

PubMed

Hong, Paul; Maguire, Erin; Gorodzinsky, Ayala Y; Curran, Janet A; Ritchie, Krista; Chorney, Jill

2016-08-01

To describe physician and parent behavior during pediatric otolaryngology surgical consultations, and to assess whether perceptions of shared decision-making and observed behavior are related. Parents of 126 children less than 6-years of age who underwent consultation for adeontonsillectomy or tympanostomy tube insertion were prospectively enrolled. Parents completed the Shared Decision-Making Questionnaire-Patient version (SDM-Q-9), while surgeons completed the Shared Decision-Making Questionnaire-Physician version (SDM-Q-Doc) after the consultation. Visits were video-recorded and analyzed using the Roter Interaction Analysis System to quantify physician and parent involvement during the consultation. Perceptions of shared decision-making between parents (SDM-Q-9) and physicians (SDM-Q-Doc) were significantly positively correlated (p = 0.03). However, there was no correlation between parents' perceptions of shared decision-making and observations of physician and parent behavior/involvement (proportion of physician socioemotional talk, task-focused talk, or proportion of parent talk). Surgeons' perceptions of shared decision-making were correlated with physician task-focused talk and proportion of parent talk. Parents and physicians had similar perceptions of the degree of shared decision-making to be taking place during pediatric otolaryngology consultations. However, there was variability in the degree to which parents participated, and parent perceptions of shared decision-making were not correlated with actual observed involvement. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

20 CFR 669.160 - How do we consult with NFJP organizations in developing rules, regulations and standards of...

Code of Federal Regulations, 2010 CFR

2010-04-01

... 20 Employees' Benefits 3 2010-04-01 2010-04-01 false How do we consult with NFJP organizations in developing rules, regulations and standards of accountability, and other policy guidance for the NFJP? 669... accountability, and other policy guidance for the NFJP? (a) We consider the NFJP grantee community as a full...

Surgical Consultation as Social Process: Implications for Shared Decision Making.

PubMed

Clapp, Justin T; Arriaga, Alexander F; Murthy, Sushila; Raper, Steven E; Schwartz, J Sanford; Barg, Frances K; Fleisher, Lee A

2017-12-12

This qualitative study examines surgical consultation as a social process and assesses its alignment with assumptions of the shared decision-making (SDM) model. SDM stresses the importance of patient preferences and rigorous discussion of therapeutic risks/benefits based on these preferences. However, empirical studies have highlighted discrepancies between SDM and realities of surgical decision making. Qualitative research can inform understanding of the decision-making process and allow for granular assessment of the nature and causes of these discrepancies. We observed consultations between 3 general surgeons and 45 patients considering undergoing 1 of 2 preference-sensitive elective operations: (1) hernia repair, or (2) cholecystectomy. These patients and surgeons also participated in semi-structured interviews. By the time of the consultation, patients and surgeons were predisposed toward certain decisions by preceding events occurring elsewhere. During the visit, surgeons had differential ability to arbitrate surgical intervention and construct the severity of patients' conditions. These upstream dynamics frequently displaced the centrality of the risk/benefit-based consent discussion. The influence of events preceding consultation suggests that decision-making models should account for broader spatiotemporal spans. Given surgeons' authority to define patients' conditions and control service provision, SDM may be premised on an overestimation of patients' power to alter the course of decision making once in a specialist's office. Considering the subordinate role of the risk/benefit discussion in many surgical decisions, it will be important to study if and how the social process of decision making is altered by SDM-oriented decision aids that foreground this discussion.

Patients' involvement in decisions about medicines: GPs' perceptions of their preferences

PubMed Central

Cox, Kate; Britten, Nicky; Hooper, Richard; White, Patrick

2007-01-01

Background Patients vary in their desire to be involved in decisions about their care. Aim To assess the accuracy and impact of GPs' perceptions of their patients' desire for involvement. Design of study Consultation-based study. Setting Five primary care centres in south London. Method Consecutive patients completed decision-making preference questionnaires before and after consultation. Eighteen GPs completed a questionnaire at the beginning of the study and reported their perceptions of patients' preferences after each consultation. Patients' satisfaction was assessed using the Medical Interview Satisfaction Scale. Analyses were conducted in 190 patient–GP pairs that identified the same medicine decision about the same main health problem. Results A total of 479 patients participated (75.7% of those approached). Thirty-nine per cent of these patients wanted their GPs to share the decision, 45% wanted the GP to be the main (28%) or only (17%) decision maker regarding their care, and 16% wanted to be the main (14%) or only (2%) decision maker themselves. GPs accurately assessed patients' preferences in 32% of the consultations studied, overestimated patients' preferences for involvement in 45%, and underestimated them in 23% of consultations studied. Factors protective against GPs underestimating patients' preferences were: patients preferring the GP to make the decision (odds ratio [OR] 0.2 per point on the five-point scale; 95% confidence interval [CI] = 0.1 to 0.4), and the patient having discussed their main health problem before (OR 0.3; 95% CI = 0.1 to 0.9). Patients' educational attainment was independently associated with GPs underestimation of preferences. Conclusion GPs' perceptions of their patients' desire to be involved in decisions about medicines are inaccurate in most cases. Doctors are more likely to underestimate patients' preferred level of involvement when patients have not consulted about their condition before. PMID:17925134

The Effect of Screen-to-Screen Versus Face-to-Face Consultation on Doctor-Patient Communication: An Experimental Study with Simulated Patients.

PubMed

Tates, Kiek; Antheunis, Marjolijn L; Kanters, Saskia; Nieboer, Theodoor E; Gerritse, Maria Be

2017-12-20

Despite the emergence of Web-based patient-provider contact, it is still unclear how the quality of Web-based doctor-patient interactions differs from face-to-face interactions. This study aimed to examine (1) the impact of a consultation medium on doctors' and patients' communicative behavior in terms of information exchange, interpersonal relationship building, and shared decision making and (2) the mediating role of doctors' and patients' communicative behavior on satisfaction with both types of consultation medium. Doctor-patient consultations on pelvic organ prolapse were simulated, both in a face-to-face and in a screen-to-screen (video) setting. Twelve medical interns and 6 simulated patients prepared 4 different written scenarios and were randomized to perform a total of 48 consultations. Effects of the consultations were measured by questionnaires that participants filled out directly after the consultation. With respect to patient-related outcomes, satisfaction, perceived information exchange, interpersonal relationship building, and perceived shared decision making showed no significant differences between face-to-face and screen-to-screen consultations. Patients' attitude toward Web-based communication (b=-.249, P=.02 and patients' perceived time and attention (b=.271, P=.03) significantly predicted patients' perceived interpersonal relationship building. Patients' perceived shared decision making was positively related to their satisfaction with the consultation (b=.254, P=.005). Overall, patients experienced significantly greater shared decision making with a female doctor (mean 4.21, SD 0.49) than with a male doctor (mean 3.66 [SD 0.73]; b=.401, P=.009). Doctor-related outcomes showed no significant differences in satisfaction, perceived information exchange, interpersonal relationship building, and perceived shared decision making between the conditions. There was a positive relationship between perceived information exchange and doctors' satisfaction with the consultation (b=.533, P<.001). Furthermore, doctors' perceived interpersonal relationship building was positively related to doctors' satisfaction with the consultation (b=.331, P=.003). In this study, the quality of doctor-patient communication, as indicated by information exchange, interpersonal relationship building, and shared decision making, did not differ significantly between Web-based and face-to-face consultations. Doctors and simulated patients were equally satisfied with both types of consultation medium, and no differences were found in the manner in which participants perceived communicative behavior during these consultations. The findings suggest that worries about a negative impact of Web-based video consultation on the quality of patient-provider consultations seem unwarranted as they offer the same interaction quality and satisfaction level as regular face-to-face consultations. ©Kiek Tates, Marjolijn L Antheunis, Saskia Kanters, Theodoor E Nieboer, Maria BE Gerritse. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 20.12.2017.

More primary care patients regret health decisions if they experienced decisional conflict in the consultation: a secondary analysis of a multicenter descriptive study.

PubMed

Becerra-Perez, Maria-Margarita; Menear, Matthew; Turcotte, Stephane; Labrecque, Michel; Légaré, France

2016-11-10

We sought to estimate the extent of decision regret among primary care patients and identify risk factors associated with regret. Secondary analysis of an observational descriptive study conducted in two Canadian provinces. Unique patient-physician dyads were recruited from 17 primary care clinics and data on patient, physician and consultation characteristics were collected before, during and immediately after consultations, as well as two weeks post-consultation, when patients completed the Decision Regret Scale (DRS). We examined the DRS score distribution and performed ordinal logistic regression analysis to identify predictors of regret. Among 258 unique patient-physicians dyads, mean ± standard deviation of decision regret scores was 11.7 ± 15.1 out of 100. Overall, 43 % of patients reported no regret, 45 % reported mild regret and 12 % reported moderate to strong regret. In multivariate analyses, higher decision regret was strongly associated with increased decisional conflict and less significantly associated with patient age and education, as well with male (vs. female) physicians and residents (vs. teachers). After consulting family physicians, most primary care patients experience little decision regret, but some experience more regret if there is decisional conflict. Strategies for reducing decisional conflict in primary care, such as shared decision-making with decision aids, seem warranted.

Emergency department evaluation and treatment of cervical spine injuries.

PubMed

Kanwar, Rajdeep; Delasobera, Bronson E; Hudson, Korin; Frohna, William

2015-05-01

Most spinal cord injuries involve the cervical spine, highlighting the importance of recognition and proper management by emergency physicians. Initial cervical spine injury management should follow the ABCDE (airway, breathing, circulation, disability, exposure) procedure detailed by Advanced Trauma Life Support. NEXUS (National Emergency X-Radiography Utilization Study) criteria and Canadian C-spine Rule are clinical decision-making tools providing guidelines of when to obtain imaging. Computed tomography scans are the preferred initial imaging modality. Consider administering intravenous methylprednisolone after discussion with the neurosurgical consultant in patients who present with spinal cord injuries within 8 hours. Copyright © 2015 Elsevier Inc. All rights reserved.

Managing Consultants.

ERIC Educational Resources Information Center

Malinconico, S. Michael

1983-01-01

Guidelines for managing library consulting engagements effectively cover the decision to use a consultant, definition of the problem area, finding the consultant, interviewing and evaluating the consultant, the psychological contract, the formal contract, and abdication of responsibility for the consulting project by the client. Seventeen sources…

The effects of consultation on over-the-counter medication purchasing decisions.

PubMed

Nichol, M B; McCombs, J S; Johnson, K A; Spacapan, S; Sclar, D A

1992-11-01

This article examines factors that predict changes in consumer purchasing decisions of nonprescription medications. Variables corresponding to factors in Andersen's behavioral model are measured, in addition to data regarding characteristics of the 17 pharmacy consultants who provided counseling services. One thousand seven hundred and thirteen consumers in five stores in southern California were provided consultation during a 6-month period, resulting in 25.4% of the patients purchasing a different drug than intended when entering the pharmacy, 1.3% being referred to a physician, and 13.4% not purchasing any over-the-counter medication at all. Logistic regression techniques demonstrated that one enabling variable (availability of generic medications), and four need factors (the discussion of clinical issues, short encounters, cough and cold products, and vitamin products) were significant predictors of the consumer's decision to purchase a different product than intended. Consultant characteristics (introversion, external locus of control) were also important predictors, but opposite the expected direction. Consumers who received information from female consultants were more likely to change their purchasing decisions.

20 CFR 404.1519 - The consultative examination.

Code of Federal Regulations, 2010 CFR

2010-04-01

... pediatrician when appropriate. The decision to purchase a consultative examination will be made on an... consultative examination. A consultative examination is a physical or mental examination or test purchased for...

20 CFR 416.919 - The consultative examination.

Code of Federal Regulations, 2010 CFR

2010-04-01

... pediatrician when appropriate. The decision to purchase a consultative examination will be made on an... consultative examination. A consultative examination is a physical or mental examination or test purchased for...

Rule acquisition in formal decision contexts based on formal, object-oriented and property-oriented concept lattices.

PubMed

Ren, Yue; Li, Jinhai; Aswani Kumar, Cherukuri; Liu, Wenqi

2014-01-01

Rule acquisition is one of the main purposes in the analysis of formal decision contexts. Up to now, there have been several types of rules in formal decision contexts such as decision rules, decision implications, and granular rules, which can be viewed as ∧-rules since all of them have the following form: "if conditions 1,2,…, and m hold, then decisions hold." In order to enrich the existing rule acquisition theory in formal decision contexts, this study puts forward two new types of rules which are called ∨-rules and ∨-∧ mixed rules based on formal, object-oriented, and property-oriented concept lattices. Moreover, a comparison of ∨-rules, ∨-∧ mixed rules, and ∧-rules is made from the perspectives of inclusion and inference relationships. Finally, some real examples and numerical experiments are conducted to compare the proposed rule acquisition algorithms with the existing one in terms of the running efficiency.

Rule Acquisition in Formal Decision Contexts Based on Formal, Object-Oriented and Property-Oriented Concept Lattices

PubMed Central

Ren, Yue; Aswani Kumar, Cherukuri; Liu, Wenqi

2014-01-01

Rule acquisition is one of the main purposes in the analysis of formal decision contexts. Up to now, there have been several types of rules in formal decision contexts such as decision rules, decision implications, and granular rules, which can be viewed as ∧-rules since all of them have the following form: “if conditions 1,2,…, and m hold, then decisions hold.” In order to enrich the existing rule acquisition theory in formal decision contexts, this study puts forward two new types of rules which are called ∨-rules and ∨-∧ mixed rules based on formal, object-oriented, and property-oriented concept lattices. Moreover, a comparison of ∨-rules, ∨-∧ mixed rules, and ∧-rules is made from the perspectives of inclusion and inference relationships. Finally, some real examples and numerical experiments are conducted to compare the proposed rule acquisition algorithms with the existing one in terms of the running efficiency. PMID:25165744

The Ayes Have It.

ERIC Educational Resources Information Center

Keating, Tom

1996-01-01

Without procedural rules, school boards could not do business. Board members consulted revealed that they agree with the rules in theory but often do not follow them in practice. Lists 10 parliamentary rules to remember. Includes a brief biography of Henry M. Robert, who originated "Robert's Rules of Order." (MLF)

High-Value Consults: A Curriculum to Promote Point-of-Care, Evidence-Based Recommendations.

PubMed

Nandiwada, Deepa Rani; Kohli, Amar; McNamara, Megan; Smith, Kenneth J; Zimmer, Shanta; McNeil, Melissa; Spagnoletti, Carla; Rubio, Doris; Berlacher, Kathryn

2017-10-01

In an era when value-based care is paramount, teaching trainees to explicitly communicate the evidence behind recommendations fosters high-value care (HVC) in the consultation process. To implement an HVC consult curriculum highlighting the need for clear consult questions, evidence-based recommendations to improve consult teaching, clinical decision-making, and the educational value of consults. A pilot curriculum was implemented for residents on cardiology consult electives utilizing faculty and fellows as evidence-based medicine (EBM) coaches. The curriculum included an online module, an EBM teaching point template, EBM presentations on rounds, and "coach" feedback on notes. A total of 15 residents and 4 fellows on cardiology consults participated, and 87% (13 of 15) of residents on consults felt the curriculum was educationally valuable. A total of 80% (72 of 90) of residents on general medicine rotations responded to the survey, and 25 of 72 residents (35%) had a consult with the EBM template. General medicine teams felt the EBM teaching points affected clinical decision-making (48%, 12 of 25) and favored dissemination of the curriculum (90%, 72 of 80). Checklist-guided chart review showed a 22% improvement in evidence-based summaries behind recommendations (7 of 36 precurriculum to 70 of 146 charts postcurriculum, P  = .015). The HVC consult curriculum during a cardiology elective was perceived by residents to influence clinical decision-making and evidence-based recommendations, and was found to be educationally valuable on both parties in the consult process.

Fostering community understanding of sufficient benefit and early stopping for a phase 2B HIV prevention clinical trial in Africa.

PubMed

White, Rhonda; Chileshe, Modesta; Dawson, Liza; Donnell, Deborah; Hillier, Sharon; Morar, Neetha; Noguchi, Lisa; Dixon, Dennis

2011-02-01

Most trials of interventions are designed to address the traditional null hypothesis of no benefit. VOICE, a phase 2B HIV prevention trial funded by NIH and conducted in Africa, is designed to assess if the intervention will prevent a substantial fraction of infections. Planned interim analysis may provide conclusive evidence against the traditional null hypothesis without establishing substantial benefit. At this interim point, the Data and Safety Monitoring Board would then face the dilemma of knowing the product has some positive effect, but perhaps not as great an effect as the protocol has declared necessary. In March 2008, NIH program staff recommended that the VOICE protocol team discuss the stopping rules with stakeholders prior to initiating the protocol. The goals of the workshop were to inform community representatives about the potential ethical dilemma associated with stopping rules and engage in dialogue about these issues. We describe the resulting community consultation and summarize the outcomes. A 2-day workshop was convened with the goal of having a clear and transparent consultation with the stakeholders around the question, 'Given emerging evidence that a product could prevent some infections, would the community support a decision to continue accruing to the trial?' Participants included research staff and community stakeholders. Lectures with visual aids, discussions, and exercises using interactive learning tasks were used, with a focus on statistics and interpreting data from trials, particularly interim data. Results of oral and written evaluations by participants were reviewed. The feedback was mostly positive, with some residual confusion regarding statistical concepts. However, discussions with attendees later revealed that not all felt prepared to engage fully in the workshop. This was the presenters' first experience facilitating a formal discussion with an audience that had no advanced science, research, or mathematics training. Community representatives' concern regarding speaking for their communities without consulting them also created a challenge for the workshop. Open discussion around trial stopping rules requires that all discussants have an understanding of trial design concepts and feel a sense of empowerment to ask and answer questions. The VOICE CWG workshop was a first step toward the goal of open discussion regarding trial stopping rules and interim results for the study; however, ongoing education and dialogue must occur to ensure that all stakeholders fully participate in the process.

Patient participation in decision-making about cardiovascular preventive drugs - resistance as agency.

PubMed

Hultberg, Josabeth; Rudebeck, Carl Edvard

2017-09-01

The aim of the study was to describe and explore patient agency through resistance in decision-making about cardiovascular preventive drugs in primary care. Six general practitioners from the southeast of Sweden audiorecorded 80 consultations. From these, 28 consultations with proposals from GPs for cardiovascular preventive drug treatments were chosen for theme-oriented discourse analysis. The study shows how patients participate in decision-making about cardiovascular preventive drug treatments through resistance in response to treatment proposals. Passive modes of resistance were withheld responses and minimal unmarked acknowledgements. Active modes were to ask questions, contest the address of an inclusive we, present an identity as a non-drugtaker, disclose non-adherence to drug treatments, and to present counterproposals. The active forms were also found in anticipation to treatment proposals from the GPs. Patients and GPs sometimes displayed mutual renouncement of responsibility for decision-making. The decision-making process appeared to expand both beyond a particular phase in the consultations and beyond the single consultation. The recognition of active and passive resistance from patients as one way of exerting agency may prove valuable when working for patient participation in clinical practice, education and research about patient-doctor communication about cardiovascular preventive medication. We propose particular attentiveness to patient agency through anticipatory resistance, patients' disclosures of non-adherence and presentations of themselves as non-drugtakers. The expansion of the decision-making process beyond single encounters points to the importance of continuity of care. KEY POINTS Guidelines recommend shared decision-making about cardiovascular preventive treatment. We need an understanding of how this is accomplished in actual consultations.This paper describes how patient agency in decision-making is displayed through different forms of resistance to treatment proposals. •The decision-making process expands beyond particular phases in consultations and beyond single encounters, implying the importance of continuity of care. •Attentiveness to patient participation through resistance in treatment negotiations is warranted in clinical practice, research and education about prescribing communication.

Got Guilt? Consultant Guilt in the Writing Center Community

ERIC Educational Resources Information Center

Nicklay, Jennifer

2012-01-01

During class discussions, the author's fellow consultants would often lament consultations that could have gone better if they had only known the "rules" of how to handle the situation. They perceived that there were acceptable and unacceptable ways to approach certain situations, rather than a range of flexible choices. The author began to…

‘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

Pilot trial of telemedicine as a decision aid for patients with chronic wounds.

PubMed

Dobke, Marek K; Bhavsar, Dhaval; Gosman, Amanda; De Neve, Joan; De Neve, Brian

2008-04-01

The study goal was to evaluate the impact of the telemedicine consult on patients with chronic wounds. Thirty patients from long-term care skilled nursing facilities, referred to the ambulatory wound care program for wound assessment and preparation of management plans, were the subject of this prospective, randomized trial. To facilitate communication with a surgical wound care specialist, telemedicine feedback was provided prior to face-to-face consultation to 15 patients. The telemedicine consult included (1) wound assessment, (2) rationale for the suggested wound management with emphasis on wound risk projections, and (3) prevention and benefits of surgical intervention. This was communicated to the patient by the field wound care nurse. The telemedicine impact was measured by assessing the duration of the subsequent face-to-face consultation and patient satisfaction with further care decisions as well as by validation of a decisional conflict scale. The average duration of the face-to-face consultation was 50 +/- 12 minutes versus 35 +/- 6 (p < 0.01) minutes for patients subjected to the telemedicine feedback preceding the direct contact with the specialist. The telemedicine consult was found to be a useful aid in increasing the satisfaction rate from care decisions ultimately made during the direct consult (acceptance rate 93% vs. 47% in those subjected to treatment without the intermediate telemedicine consult, p < 0.01). The decisional conflict as a state of uncertainty about the course of action to take was reduced in patients subjected to telemedicine decision aid. The average Decisional Conflict Scale score was 14 +/- 1.73 in patients subjected to telemedicine feedback as opposed to 35 +/- 4.26 (p < 0.001) in no-telemedicine contact. The telemedicine consult preceding face-to-face evaluation improved patient satisfaction and understanding of their care as well as increased the perception of shared decision making regarding the wound care.

Inside the black box of shared decision making: distinguishing between the process of involvement and who makes the decision

PubMed Central

Edwards, Adrian; Elwyn, Glyn

2006-01-01

Abstract Background  Shared decision making has practical implications for everyday health care. However, it stems from largely theoretical frameworks and is not widely implemented in routine practice. Aims  We undertook an empirical study to inform understanding of shared decision making and how it can be operationalized more widely. Method  The study involved patients visiting UK general practitioners already well experienced in shared decision making. After these consultations, semi‐structured telephone interviews were conducted and analysed using the constant comparative method of content analysis. Results  All patients described at least some components of shared decision making but half appeared to perceive the decision as shared and half as ‘patient‐led’. However, patients exhibited some uncertainty about who had made the decision, reflecting different meanings of decision making from those described in the literature. A distinction is indicated between the process of involvement (option portrayal, exchange of information and exploring preferences for who makes the decision) and the actual decisional responsibility (who makes the decision). The process of involvement appeared to deliver benefits for patients, not the action of making the decision. Preferences for decisional responsibility varied during some consultations, generating unsatisfactory interactions when actual decisional responsibility did not align with patient preferences at that stage of a consultation. However, when conducted well, shared decision making enhanced reported satisfaction, understanding and confidence in the decisions. Conclusions  Practitioners can focus more on the process of involving patients in decision making rather than attaching importance to who actually makes the decision. They also need to be aware of the potential for changing patient preferences for decisional responsibility during a consultation and address non‐alignment of patient preferences with the actual model of decision making if this occurs. PMID:17083558

Effective follow-up consultations: the importance of patient-centered communication and shared decision making.

PubMed

Brand, Paul L P; Stiggelbout, Anne M

2013-12-01

Paediatricians spend a considerable proportion of their time performing follow-up visits for children with chronic conditions, but they rarely receive specific training on how best to perform such consultations. The traditional method of running a follow-up consultation is based on the doctor's agenda, and is problem-oriented. Patients and parents, however, prefer a patient-centered, and solution-focused approach. Although many physicians now recognize the importance of addressing the patient's perspective in a follow-up consultation, a number of barriers hamper its implementation in practice, including time constraints, lack of appropriate training, and a strong tradition of the biomedical, doctor-centered approach. Addressing the patient's perspective successfully can be achieved through shared decision making, clinicians and patients making decisions together based on the best clinical evidence. Research shows that shared decision making not only increases patient, parent, and physician satisfaction with the consultation, but also may improve health outcomes. Shared decision making involves building a physician-patient-parent partnership, agreeing on the problem at hand, laying out the available options with their benefits and risks, eliciting the patient's views and preferences on these options, and agreeing on a course of action. Shared decision making requires specific communication skills, which can be learned, and should be mastered through deliberate practice. Copyright © 2013 Elsevier Ltd. All rights reserved.

Taking a gamble or playing by the rules: Dissociable prefrontal systems implicated in probabilistic versus deterministic rule-based decisions

PubMed Central

Bhanji, Jamil P.; Beer, Jennifer S.; Bunge, Silvia A.

2014-01-01

A decision may be difficult because complex information processing is required to evaluate choices according to deterministic decision rules and/or because it is not certain which choice will lead to the best outcome in a probabilistic context. Factors that tax decision making such as decision rule complexity and low decision certainty should be disambiguated for a more complete understanding of the decision making process. Previous studies have examined the brain regions that are modulated by decision rule complexity or by decision certainty but have not examined these factors together in the context of a single task or study. In the present functional magnetic resonance imaging study, both decision rule complexity and decision certainty were varied in comparable decision tasks. Further, the level of certainty about which choice to make (choice certainty) was varied separately from certainty about the final outcome resulting from a choice (outcome certainty). Lateral prefrontal cortex, dorsal anterior cingulate cortex, and bilateral anterior insula were modulated by decision rule complexity. Anterior insula was engaged more strongly by low than high choice certainty decisions, whereas ventromedial prefrontal cortex showed the opposite pattern. These regions showed no effect of the independent manipulation of outcome certainty. The results disambiguate the influence of decision rule complexity, choice certainty, and outcome certainty on activity in diverse brain regions that have been implicated in decision making. Lateral prefrontal cortex plays a key role in implementing deterministic decision rules, ventromedial prefrontal cortex in probabilistic rules, and anterior insula in both. PMID:19781652

Medication decision making and patient outcomes in GP, nurse and pharmacist prescriber consultations.

PubMed

Weiss, Marjorie C; Platt, Jo; Riley, Ruth; Chewning, Betty; Taylor, Gordon; Horrocks, Susan; Taylor, Andrea

2015-09-01

Aim The aims of this study were twofold: (a) to explore whether specific components of shared decision making were present in consultations involving nurse prescribers (NPs), pharmacist prescribers (PPs) and general practitioners (GPs) and (b) to relate these to self-reported patient outcomes including satisfaction, adherence and patient perceptions of practitioner empathy. There are a range of ways for defining and measuring the process of concordance, or shared decision making as it relates to decisions about medicines. As a result, demonstrating a convincing link between shared decision making and patient benefit is challenging. In the United Kingdom, nurses and pharmacists can now take on a prescribing role, engaging in shared decision making. Given the different professional backgrounds of GPs, NPs and PPs, this study sought to explore the process of shared decision making across these three prescriber groups. Analysis of audio-recordings of consultations in primary care in South England between patients and GPs, NPs and PPs. Analysis of patient questionnaires completed post consultation. Findings A total of 532 consultations were audio-recorded with 20 GPs, 19 NPs and 12 PPs. Prescribing decisions occurred in 421 (79%). Patients were given treatment options in 21% (102/482) of decisions, the prescriber elicited the patient's treatment preference in 18% (88/482) and the patient expressed a treatment preference in 24% (118/482) of decisions. PPs were more likely to ask for the patient's preference about their treatment regimen (χ 2=6.6, P=0.036, Cramer's V=0.12) than either NPs or GPs. Of the 275 patient questionnaires, 192(70%) could be matched with a prescribing decision. NP patients had higher satisfaction levels than patients of GPs or PPs. More time describing treatment options was associated with increased satisfaction, adherence and greater perceived practitioner empathy. While defining, measuring and enabling the process of shared decision making remains challenging, it may have patient benefit.

Decision-making in multiple sclerosis consultations in Italy: third observer and patient assessments.

PubMed

Pietrolongo, Erika; Giordano, Andrea; Kleinefeld, Monica; Confalonieri, Paolo; Lugaresi, Alessandra; Tortorella, Carla; Pugliatti, Maura; Radice, Davide; Goss, Claudia; Heesen, Christoph; Solari, Alessandra

2013-01-01

To assess decision-making in multiple sclerosis (MS) from third observer and patient perspectives. Audio recordings of first-ever consultations with a participating physician (88 outpatients, 10 physicians) at four tertiary MS care clinics in Italy, were rated by a third observer using the Observing Patient Involvement in Shared Decision Making (OPTION) and by patients using the Perceived Involvement in Care Scale (PICS). Mean patient age was 37.5, 66% were women, 72% had MS, and 28% had possible MS or other disease. Mean PICS subscale scores (range 0 poor, 100 best possible) were 71.9 (SD 24.3) for "physician facilitation" (PICS-F); 74.6 (SD 22.9) for "patient information exchange" (PICS-I); and only 22.5 (SD 16.2) for "patient decision making" (PICS-DM). Mean OPTION total score (0 poor, 100 best possible) was 29.6 (SD 10.3). Poorest OPTION scores were found for items assessing "preferred patient approach to receiving information" and "preferred patient level of involvement." Highest scores were for "clinician drawing attention to identified problem", "indicating need for decision making," and "need to review the decision." Consultation time, woman physician, patient-physician gender concordance and PICS-F were associated with higher OPTION total score; older physician and second opinion consultation were associated with lower OPTION score. In line with findings in other settings, our third observer findings indicated limited patient involvement abilities of MS physicians during first consultations. Patient perceptions of physician skills were better than third observers', although they correlated. Consultations with women physicians, and younger physicians, were associated with higher third observer and patient-based scores. Our findings reveal a need to empower Italian MS physicians with better communication and shared decision-making skills, and show in particular that attention to MS patient preferences for reception of information and involvement in health decisions, need to be improved.

Adaptive Comanagement of a Marine Protected Area Network in Fiji

PubMed Central

WEEKS, REBECCA; JUPITER, STACY D

2014-01-01

Adaptive management of natural resources is an iterative process of decision making whereby management strategies are progressively changed or adjusted in response to new information. Despite an increasing focus on the need for adaptive conservation strategies, there remain few applied examples. We describe the 9-year process of adaptive comanagement of a marine protected area network in Kubulau District, Fiji. In 2011, a review of protected area boundaries and management rules was motivated by the need to enhance management effectiveness and the desire to improve resilience to climate change. Through a series of consultations, with the Wildlife Conservation Society providing scientific input to community decision making, the network of marine protected areas was reconfigured so as to maximize resilience and compliance. Factors identified as contributing to this outcome include well-defined resource-access rights; community respect for a flexible system of customary governance; long-term commitment and presence of comanagement partners; supportive policy environment for comanagement; synthesis of traditional management approaches with systematic monitoring; and district-wide coordination, which provided a broader spatial context for adaptive-management decision making. PMID:24112643

The Impact of Telemedicine on Pediatric Critical Care Triage.

PubMed

Harvey, Jillian B; Yeager, Brooke E; Cramer, Christina; Wheeler, David; McSwain, S David

2017-11-01

To examine the relationship between pediatric critical care telemedicine consultation to rural emergency departments and triage decisions. We compare the triage location and provider rating of the accuracy of remote assessment for a cohort of patients who receive critical care telemedicine consultations and a similar group of patients receiving telephone consultations. Retrospective evaluation of consultations occurring between April 2012 and March 2016. Pediatric critical care telemedicine and telephone consultations in 52 rural healthcare settings in South Carolina. Pediatric patients receiving critical care telemedicine or telephone consultations. Telemedicine consultations. Data were collected from the consulting provider for 484 total consultations by telephone or telemedicine. We examined the providers' self-reported assessments about the consultation, decision-making, and triage outcomes. We estimate a logit model to predict triage location as a function of telemedicine consult age and sex. For telemedicine patients, the odds of triage to a non-ICU level of care are 2.55 times larger than the odds for patients receiving telephone consultations (p = 0.0005). Providers rated the accuracy of their assessments higher when consultations were provided via telemedicine. When patients were transferred to a non-ICU location following a telemedicine consultation, providers indicated that the use of telemedicine influenced the triage decision in 95.7% of cases (p < 0.001). For patients transferred to a non-ICU location, an increase in transfers to a higher level of care within 24 hours was not observed. Pediatric critical care telemedicine consultation to community hospitals is feasible and results in a reduction in PICU admissions. This study demonstrates an improvement in provider-reported accuracy of patient assessment via telemedicine compared with telephone, which may produce a higher comfort level with transporting patients to a lower level of care. Pediatric critical care telemedicine consultations represent a promising means of improving care and reducing costs for critically ill children in rural areas.

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

PubMed

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

2018-04-01

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

Influence of Men's Personality and Social Support on Treatment Decision-Making for Localized Prostate Cancer.

PubMed

Reamer, Elyse; Yang, Felix; Holmes-Rovner, Margaret; Liu, Joe; Xu, Jinping

2017-01-01

Optimal treatment for localized prostate cancer (LPC) is controversial. We assessed the effects of personality, specialists seen, and involvement of spouse, family, or friends on treatment decision/decision-making qualities. We surveyed a population-based sample of men ≤ 75 years with newly diagnosed LPC about treatment choice, reasons for the choice, decision-making difficulty, satisfaction, and regret. Of 160 men (71 black, 89 white), with a mean age of 61 (±7.3) years, 59% chose surgery, 31% chose radiation, and 10% chose active surveillance (AS)/watchful waiting (WW). Adjusting for age, race, comorbidity, tumor risk level, and treatment status, men who consulted friends during decision-making were more likely to choose curative treatment (radiation or surgery) than WW/AS (OR = 11.1, p < 0.01; 8.7, p < 0.01). Men who saw a radiation oncologist in addition to a urologist were more likely to choose radiation than surgery (OR = 6.0, p = 0.04). Men who consulted family or friends (OR = 2.6, p < 0.01; 3.7, p < 0.01) experienced greater decision-making difficulty. No personality traits (pessimism, optimism, or faith) were associated with treatment choice/decision-making quality measures. In addition to specialist seen, consulting friends increased men's likelihood of choosing curative treatment. Consulting family or friends increased decision-making difficulty.

Consulting about Consulting: Young People's Views of Consultation

ERIC Educational Resources Information Center

Woolfson, Richard C.; Harker, Michael; Lowe, Dorothy; Shields, Mary; Banks, Margaret; Campbell, Lindsay; Ferguson, Ellen

2006-01-01

The increasing recognition that children and young people should be consulted and involved in decision-making about their lives is reflected in national and international legislation. A great deal of this legislation, stemming from the UN convention on the Rights of the Child (1989), requires education authorities to consult children and young…

5 CFR 950.303 - Local federations eligibility.

Code of Federal Regulations, 2010 CFR

2010-01-01

... of failure to correct a prior violation may appeal the LFCC's decision to the Director in accordance... services of private consultants, consulting firms, advertising agencies or similar business organizations... appeal an adverse eligibility decision in accordance with § 950.205. (g) The Director may waive any...

Patient participation in decision-making about cardiovascular preventive drugs – resistance as agency

PubMed Central

Hultberg, Josabeth; Rudebeck, Carl Edvard

2017-01-01

Objective The aim of the study was to describe and explore patient agency through resistance in decision-making about cardiovascular preventive drugs in primary care. Design Six general practitioners from the southeast of Sweden audiorecorded 80 consultations. From these, 28 consultations with proposals from GPs for cardiovascular preventive drug treatments were chosen for theme-oriented discourse analysis. Results The study shows how patients participate in decision-making about cardiovascular preventive drug treatments through resistance in response to treatment proposals. Passive modes of resistance were withheld responses and minimal unmarked acknowledgements. Active modes were to ask questions, contest the address of an inclusive we, present an identity as a non-drugtaker, disclose non-adherence to drug treatments, and to present counterproposals. The active forms were also found in anticipation to treatment proposals from the GPs. Patients and GPs sometimes displayed mutual renouncement of responsibility for decision-making. The decision-making process appeared to expand both beyond a particular phase in the consultations and beyond the single consultation. Conclusions The recognition of active and passive resistance from patients as one way of exerting agency may prove valuable when working for patient participation in clinical practice, education and research about patient–doctor communication about cardiovascular preventive medication. We propose particular attentiveness to patient agency through anticipatory resistance, patients’ disclosures of non-adherence and presentations of themselves as non-drugtakers. The expansion of the decision-making process beyond single encounters points to the importance of continuity of care. KEY POINTS Guidelines recommend shared decision-making about cardiovascular preventive treatment. We need an understanding of how this is accomplished in actual consultations.This paper describes how patient agency in decision-making is displayed through different forms of resistance to treatment proposals. •The decision-making process expands beyond particular phases in consultations and beyond single encounters, implying the importance of continuity of care. •Attentiveness to patient participation through resistance in treatment negotiations is warranted in clinical practice, research and education about prescribing communication. PMID:28277056

GPs' interactional styles in consultations with Dutch and ethnic minority patients.

PubMed

Schouten, Barbara C; Meeuwesen, Ludwien; Harmsen, Hans A M

2009-12-01

The aim of this study was to examine interactional styles of general practitioners (GPs) in consultations with Dutch patients as compared to ethnic minority patients, from the perspective of level of mutual understanding between patient and GP. Data of 103 transcripts of video-registered medical interviews were analyzed to assess GPs' communication styles in terms of involvement, detachment, shared decision-making and patient-centeredness. Surveys were used to collect data on patients' characteristics and mutual understanding. Results show that overall, GPs communicate less adequately with ethnic minority patients than with Dutch patients; they involve them less in decision-making and check their understanding of what has been discussed less often. Intercultural consultations are thus markedly distinguishable from intracultural consultations by a lack of adequate communicative behavior by GPs. As every patient has a moral and legal right to make informed decisions, it is concluded that GPs should check more often whether their ethnic minority patients have understood what has been said during the medical consultation.

5 CFR 251.201 - Associations of management officials and/or supervisors.

Code of Federal Regulations, 2014 CFR

2014-01-01

.../or supervisors. 251.201 Section 251.201 Administrative Personnel OFFICE OF PERSONNEL MANAGEMENT CIVIL... managers should be included in the decision-making process and notified of executive-level decisions on a... consultation with its supervisors and managers. Agencies must also establish consultative relationships with...

5 CFR 251.201 - Associations of management officials and/or supervisors.

Code of Federal Regulations, 2012 CFR

2012-01-01

.../or supervisors. 251.201 Section 251.201 Administrative Personnel OFFICE OF PERSONNEL MANAGEMENT CIVIL... managers should be included in the decision-making process and notified of executive-level decisions on a... consultation with its supervisors and managers. Agencies must also establish consultative relationships with...

20 CFR 405.220 - Decision by the Federal reviewing official.

Code of Federal Regulations, 2011 CFR

2011-04-01

... PROCESS FOR ADJUDICATING INITIAL DISABILITY CLAIMS Review of Initial Determinations by a Federal Reviewing... his or her decision, the Federal reviewing official may consult with a medical, psychological, or... evidence, the Federal reviewing official will consult with a medical or psychological expert through the...

Evaluation of the performance of statistical tests used in making cleanup decisions at Superfund sites. Part 1: Choosing an appropriate statistical test

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

Berman, D.W.; Allen, B.C.; Van Landingham, C.B.

1998-12-31

The decision rules commonly employed to determine the need for cleanup are evaluated both to identify conditions under which they lead to erroneous conclusions and to quantify the rate that such errors occur. Their performance is also compared with that of other applicable decision rules. The authors based the evaluation of decision rules on simulations. Results are presented as power curves. These curves demonstrate that the degree of statistical control achieved is independent of the form of the null hypothesis. The loss of statistical control that occurs when a decision rule is applied to a data set that does notmore » satisfy the rule`s validity criteria is also clearly demonstrated. Some of the rules evaluated do not offer the formal statistical control that is an inherent design feature of other rules. Nevertheless, results indicate that such informal decision rules may provide superior overall control of error rates, when their application is restricted to data exhibiting particular characteristics. The results reported here are limited to decision rules applied to uncensored and lognormally distributed data. To optimize decision rules, it is necessary to evaluate their behavior when applied to data exhibiting a range of characteristics that bracket those common to field data. The performance of decision rules applied to data sets exhibiting a broader range of characteristics is reported in the second paper of this study.« less

Evaluation of a rule base for decision making in general practice.

PubMed Central

Essex, B; Healy, M

1994-01-01

BACKGROUND. Decision making in general practice relies heavily on judgmental expertise. It should be possible to codify this expertise into rules and principles. AIM. A study was undertaken to evaluate the effectiveness, of rules from a rule base designed to improve students' and trainees' management decisions relating to patients seen in general practice. METHOD. The rule base was developed after studying decisions about and management of thousands of patients seen in one general practice over an eight year period. Vignettes were presented to 93 fourth year medical students and 179 general practitioner trainees. They recorded their perception and management of each case before and after being presented with a selection of relevant rules. Participants also commented on their level of agreement with each of the rules provided with the vignettes. A panel of five independent assessors then rated as good, acceptable or poor, the participants' perception and management of each case before and after seeing the rules. RESULTS. Exposure to a few selected rules of thumb improved the problem perception and management decisions of both undergraduates and trainees. The degree of improvement was not related to previous experience or to the stated level of agreement with the proposed rules. The assessors identified difficulties students and trainees experienced in changing their perceptions and management decisions when the rules suggested options they had not considered. CONCLUSION. The rules developed to improve decision making skills in general practice are effective when used with vignettes. The next phase is to transform the rule base into an expert system to train students and doctors to acquire decision making skills. It could also be used to provide decision support when confronted with difficult management decisions in general practice. PMID:8204334

Teaching with audiovisual recordings of consultations

PubMed Central

Davis, R. H.; Jenkins, M.; Smail, S. A.; Stott, N. C. H.; Verby, J.; Wallace, B. B.

1980-01-01

The experience gained from two years' teaching with audiovisual recordings of consultations of both undergraduates and postgraduates is presented. Some basic teaching rules are suggested and further applications of the technique are discussed. ImagesFigure 1.Figure 2.Figure 3. PMID:6157811

Game Methods of Collective Decision Making in Management Consulting.

ERIC Educational Resources Information Center

Prigozhin, Arkadii Il'ich

1991-01-01

Explores former Soviet management consultants' increased use of social psychological game methods. Identifies such games as means of involving segments of client organizations in accomplishing shared tasks. Proposes a "practical" business game, designed to shape the process of formulating new management decisions at a radical level.…

The impact of a telehealth web-based solution on neurosurgery triage and consultation.

PubMed

Moya, Monica; Valdez, Jessica; Yonas, Howard; Alverson, Dale C

2010-11-01

To enhance the quality of neurosurgery consultations, triage, and transport decisions between a Level I trauma service neurosurgery program at the University of New Mexico Hospital and referring hospitals, a secure Health Insurance Portability and Accountability Act (HIPAA)-compliant Web-based system was developed, to which digital neurological images could be sent for review by a neurosurgeon for consultation or patient transfer. Based upon prior experience of neurosurgery, it was predicted that 25% of transfer requests would be avoided if the neurosurgeons reviewed the computerized tomography scans at the time of a transfer request. In addition, it was predicted in 25% of the case that changes in management recommendations would take place independent of the transfer decision. The program was designed to allow referring hospitals to transmit digital images to the Web site, providing consulting doctors with additional patient information. This project analyzed the neurosurgeons' responses to questions designed to determine if transport or management decisions were altered when using this telehealth program in response to a request for consultation or transfer from a rural facility. Analysis of the responses of the consulting neurosurgeons revealed that, after viewing the images, 44% of the potential transfers were avoided and 44% of consulted cases resulted in management recommendation changes independent of the transfer decision. Use of the system resulted in improved triage and changes in transfer or management recommendations. A significant number of potential transfers were avoided, resulting in transport cost avoidance, more effective use of resources, and more appropriate use of the neurosurgery service as well as improved patient preparation.

Information giving and involvement in treatment decisions: is more really better? Psychological effects and relation with adherence.

PubMed

Wroe, Abigail L; Salkovskis, Paul M; Rees, Margaret; Jack, Tim

2013-01-01

The aim of this study is to improve our understanding of the ways in which a medical consultation style relates to satisfaction and adherence. Participants completed questionnaires about preferred and perceived consultation styles; psychological variables such as satisfaction, anxiety and depression; and questions about taking medication. Questionnaires were completed prior to the consultation, immediately after, three months later and one year later. Doctors also completed a scale on completion of the consultation. The decisions in question related to women seeking advice about Hormone Replacement Therapy (HRT) and decisions about pain management. Patients expressed preferences for information about the treatment options and for active involvement in the decision process. The extent to which patients perceived themselves as having received information about the treatment options was a particularly consistent predictor of satisfaction. The extent to which patients perceived themselves as having been prepared for the side effects of HRT was a consistent predictor of anxiety. Perceptions of the amount of information received about medical options, including information preparing individuals for potential side effects of medication, appears to be more important to satisfaction and anxiety, than actual involvement in the decision.

In thunder, lightning or in rain: what three doctors can do.

PubMed

Annas, G J

1987-01-01

Annas discusses three 1987 New Jersey Supreme Court cases in which the court decided that life-sustaining treatment could be terminated either because this was what the patient clearly wanted (In re Farrell and In re Peter) or because it was the family's best judgment of what the patient wanted (In re Jobes). He is critical of the court's opinions because they appear to place limits on the right to refuse treatment through the use of procedural "rules." By categorizing patients in terms of, for example, being in a persistent vegetative state, and by requiring medical consultations in cases involving refusal of life-sustaining treatment, the court followed the Quinlan precedent of focusing on decision making by physicians.

Caring Decisions: The Development of a Written Resource for Parents Facing End-of-Life Decisions

PubMed Central

Gillam, Lynn; Hynson, Jenny; Sullivan, Jane; Cossich, Mary; Wilkinson, Dominic

2015-01-01

Abstract Background: Written resources in adult intensive care have been shown to benefit families facing end of life (EoL) decisions. There are few resources for parents making EoL decisions for their child and no existing resources addressing ethical issues. The Caring Decisions handbook and website were developed to fill these gaps. Aim: We discuss the development of the resources, modification after reviewer feedback and findings from initial pilot implementation. Design: A targeted literature review-to identify resources and factors that impact on parental EoL decision-making; development phase-guided by the literature and the researchers' expertise; consultation process-comprised a multi-disciplinary panel of experts and parents; pilot evaluation study-hard-copy handbook was distributed as part of routine care at an Australian Children's Hospital. Setting/Participants: Twelve experts and parents formed the consultation panel. Eight parents of children with life-limiting conditions and clinicians were interviewed in the pilot study. Results: Numerous factors supporting/impeding EoL decisions were identified. Caring Decisions addressed issues identified in the literature and by the multidisciplinary research team. The consultation panel provided overwhelmingly positive feedback. Pilot study parents found the resources helpful and comforting. Most clinicians viewed the resources as very beneficial to parents and identified them as ideal for training purposes. Conclusions: The development of the resources addressed many of the gaps in existing resources. The consultation process and the pilot study suggest these resources could be of significant benefit to parents and clinicians. PMID:26418215

Transforming data into action: the Sonoma County Human Services Department.

PubMed

Harrison, Lindsay

2012-01-01

In order to centralize data-based initiatives, the Director of the Department worked with the Board of Supervisors and the executive team to develop a new Planning, Research, and Evaluation (PRE) division. PRE is establishing rules for data-based decision making and consolidating data collection to ensure quality and consistency. It aims to target resources toward visionary, pro-active program planning and implementation, and inform the public about the role of Human Services in creating a healthy, safe and productive environment. PRE staff spent several months studying the job functions of staff, to determine how they use information to inform practice, consulting other counties about their experiences. The PRE team developed Datascript, outlining two agency aims: (a) foster a decision-making environment that values and successfully uses empirical evidence for strategic change, and (b) manage the role and image of the Human Services Department in the external environment. The case study describes action steps developed to achieve each aim. Copyright © Taylor & Francis Group, LLC

78 FR 48342 - Consultation Agreements: Proposed Changes to Consultation Procedures

Federal Register 2010, 2011, 2012, 2013, 2014

2013-08-08

... AGENCY: Occupational Safety and Health Administration (OSHA), Labor. ACTION: Withdrawal of proposed rule; termination of rulemaking. SUMMARY: The Occupational Safety and Health Administration (OSHA) published a... DEPARTMENT OF LABOR Occupational Safety and Health Administration 29 CFR Part 1908 [Docket No...

Comparison of ethical judgments exhibited by clients and ethics consultants in Japan.

PubMed

Nagao, Noriko; Kadooka, Yasuhiro; Asai, Atsushi

2014-03-04

Healthcare professionals must make decisions for patients based on ethical considerations. However, they rely on clinical ethics consultations (CEC) to review ethical justifications of their decisions. CEC consultants support the cases reviewed and guide medical care. When both healthcare professionals and CEC consultants face ethical problems in medical care, how is their judgment derived? How do medical judgments differ from the ethical considerations of CECs? This study examines CECs in Japan to identify differences in the ethical judgment of clients and CEC consultants. The CEC request and response documents of all 60 cases reviewed across Japan between October 2006 and the end of October 2011 were classified in terms of the presence of decisional capacity in the patient. We conducted a qualitative content analysis of the differences in reasoning between client and CEC consultants. Reasoned judgments were verified in individual cases to classify the similarities or differences of opinion between CEC clients and teams. As the result of classification of the decisional capacity and the difference of opinion regarding medical care, the most frequent category was 25 cases (41.7%) of "uncertain decisional capacity," and 23 cases (38.3%) of "withholding of decision-making." A chi-square analysis was performed on presence of decisional capacity and agreement in decision-making, yielding a statistically significant difference (p < 0.05). The CEC consultants' reasoning was based on "patient's preference was ambiguous," "validity of family as a surrogate," "estimation of patient preference," and "patient's best interest," whereas the CEC client's reasoning was based on "consistent family preference was shown/not shown" and "appropriate therapeutic methods to manage patient safety." Differences in opinions were found in cases classified according to decisional capacity. Furthermore, the reasoning behind judgments differed between CEC clients and CEC consultants. The reasoning of CEC consultants was critical and reflective, while for clients it was situational and pragmatic.

Investigating a self-scoring interview simulation for learning and assessment in the medical consultation.

PubMed

Bruen, Catherine; Kreiter, Clarence; Wade, Vincent; Pawlikowska, Teresa

2017-01-01

Experience with simulated patients supports undergraduate learning of medical consultation skills. Adaptive simulations are being introduced into this environment. The authors investigate whether it can underpin valid and reliable assessment by conducting a generalizability analysis using IT data analytics from the interaction of medical students (in psychiatry) with adaptive simulations to explore the feasibility of adaptive simulations for supporting automated learning and assessment. The generalizability (G) study was focused on two clinically relevant variables: clinical decision points and communication skills. While the G study on the communication skills score yielded low levels of true score variance, the results produced by the decision points, indicating clinical decision-making and confirming user knowledge of the process of the Calgary-Cambridge model of consultation, produced reliability levels similar to what might be expected with rater-based scoring. The findings indicate that adaptive simulations have potential as a teaching and assessment tool for medical consultations.

When do cancer patients regret their treatment decision? A path analysis of the influence of clinicians' communication styles and the match of decision-making styles on decision regret.

PubMed

Nicolai, Jennifer; Buchholz, Angela; Seefried, Nathalie; Reuter, Katrin; Härter, Martin; Eich, Wolfgang; Bieber, Christiane

2016-05-01

To test the influence of physician empathy (PE), shared decision making (SDM), and the match between patients' preferred and perceived decision-making styles on patients' decision regret. Patients with breast or colon cancer (n=71) completed questionnaires immediately following (T1) and three months after a consultation (T2). Path analysis was used to examine the relationships among patient demographics, patient reports of PE, SDM, the match between preferred and perceived decision-making styles, and patient decision regret at T2. After controlling for clinician clusters, higher PE was directly associated with more SDM (β=0.43, p<0.01) and lower decision regret (β=-0.28, p<0.01). The match between patients' preferred and perceived roles was negatively associated with decision regret (β=-0.33, p<0.01). Patients who participated less than desired reported more decision regret at T2. There was no significant association between SDM and decision regret (β=0.03, p=0.74). PE and the match between patients' preferred and perceived roles in medical decision making are essential for patient-centered cancer consultations and treatment decisions. Ways to enhance PE and matching the consultation style to patients' expectations should be encouraged. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

Everyday ethics: learning from an ‘ordinary’ consultation in general practice

PubMed Central

2011-01-01

The author uses a constructed case to analyse some of the ethical decisions that UK general practitioners face in everyday settings. A variety of ethical frameworks and empirical primary healthcare literature are used to demonstrate how ethical tools may be used by clinicians in primary healthcare to reflect on their decisions in practice. The GP consultation context can make ‘on the spot’ ethical decisions difficult and varied. PMID:25949652

Exploring the communication of oncologists, patients and family members in cancer consultations: development and application of a coding system capturing family-relevant behaviours (KINcode).

PubMed

Laidsaar-Powell, Rebekah; Butow, Phyllis; Bu, Stella; Dear, Rachel; Fisher, Alana; Coll, Joseph; Juraskova, Ilona

2016-07-01

Family members (FMs) regularly attend oncology consultations. However, limited studies have assessed actual behaviours of oncologists, patients and FMs - particularly during decision-making. The current study aimed the following: (i) to rigorously develop a family (kin) interaction coding system (KINcode) capturing communication and decision-making behaviours of FMs and family-relevant behaviours of oncologists and patients and (ii) to apply KINcode to initial oncology consultations. The 80-item KINcode system was developed and applied to 72 transcripts of audiotaped medical/radiation oncology consultations including an FM, collected as part of two previous studies. The role of the FM varied considerably within the one encounter, with 33% of FMs assuming three or more roles across the four consultation stages. Whilst most FMs asked treatment decision questions (71%), a minority engaged in other behaviours such as prompting patient questions (4%) or providing information relevant to the decision to the oncologist (18%). Although oncologists rarely initiated interaction with FMs such as in rapport building (18%) or asking FMs questions (25%), they were typically fully responsive to FM questions (90%). Many patients asked their FM a question (42%), but few elicited the FM's decision preferences (4%). This study provides novel insights into the complex nature of family involvement. The findings highlight potentially positive FM-focused consultation behaviours such as oncologist responsiveness to family questions and potential areas for improvement such as rapport building, invitation of questions and validation of the family's role. Family-specific communication skills training should be considered in medical student and professional education settings. Copyright © 2015 John Wiley & Sons, Ltd. Copyright © 2015 John Wiley & Sons, Ltd.

A Model to Assess the Behavioral Impacts of Consultative Knowledge Based Systems.

ERIC Educational Resources Information Center

Mak, Brenda; Lyytinen, Kalle

1997-01-01

This research model studies the behavioral impacts of consultative knowledge based systems (KBS). A study of graduate students explored to what extent their decisions were affected by user participation in updating the knowledge base; ambiguity of decision setting; routinization of usage; and source credibility of the expertise embedded in the…

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

PubMed Central

2012-01-01

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

Antibiotics for coughing in general practice: a qualitative decision analysis.

PubMed

Coenen, S; Van Royen, P; Vermeire, E; Hermann, I; Denekens, J

2000-10-01

In family practice, medical decisions are prompted most often by complaints about coughing. There is no single yardstick for the differential diagnosis of respiratory tract infections (RTIs). In 80% of cases, the excessive use of antibiotics in the treatment of RTIs is caused by the prescription behaviour of GPs. Our aim was to explicate GPs' diagnostic (and therapeutic) decisions regarding adult patients who consult them with complaints about coughing, and to investigate what determines decision making. Exploratory, descriptive focus groups were held with GPs. Hypotheses were generated on the basis of 'qualitative content analysis'. Results. Twenty-four GPs participated in four semi-structured group discussions. In order to differentiate RTIs from other possible diagnoses, less likely diagnoses were not ruled out explicitly. In the case of suspected RTI, there was a low degree of certainty in the differentiation between RTIs (e.g. between bronchitis and pneumonia). Clinical signs and symptoms, which determine the probability of disease, often left GPs with reasonable diagnostic doubt. In the end, the decision whether or not to prescribe antibiotics was taken. GPs' prescription behaviour was also determined by doctor- and patient-related factors (e.g. having missed pneumonia once, patient expectations). The 'chagrin factor' explains why these factors lead to a shift in the action threshold, in favour of antibiotics. This inductive research method enabled the generation of meaningful hypotheses regarding the complex decision processes pursued by GPs. The authors are developing an educational intervention that builds on these findings, focusing on the prescribing decision.

The Practice of Educational Consultancy in the Context of Policy Formation.

ERIC Educational Resources Information Center

Davies, John L.

The effectiveness, behavior, and role of the consultant as policy advisor is examined in light of three operating assumptions: (1) that educational organiztions are subject to politicization; (2) that the consultant's primary role is to assist in nonroutine, potentially controversial policy decisions; and (3) that the consultant must therefore…

Men's Knowledge About Maternal Serum Screening for Down Syndrome and their Attitude Towards Amniocentesis.

PubMed

Brajenović-Milić, Bojana; Dorčić, Tamara Martinac

2017-02-01

The present study aimed to assess (i) the impact of screening consultation on male partner's knowledge about second trimester maternal serum screening for Down syndrome and on their attitudes toward amniocentesis, and (ii) the concomitant effect of men's involvement in pregnancy on both knowledge and attitudes. The study included 164 men who accompanied their partners to the screening appointment. Knowledge Questionnaire and Partner's Involvement in Pregnancy Scale with two dimensions, support and distance, were administered. Involvement in pregnancy was determined using two factors; support and distance. Findings revealed a significant post-consultation improvement in men's knowledge about the test, but less-educated men and those who were more distanced from partner and pregnancy were less knowledgeable even post-consultation. Compared to before the consultation, most men had a positive attitude toward amniocentesis and were willing to suggest it to their partners in case of positive test results (77 % and 42 %, respectively). The remainder would either leave the decision to their partners (20 %) or were undecided (3 %). Higher perception of distance was associated with men's unwillingness to be involved in amniocentesis decisions, particularly before consultation. However, the consultation had considerable potential to engage men with this attitude in the decision-making process. The study highlights the need to change woman-oriented prenatal screening practices for Down syndrome to involve their male partners in the consultation.

Clinicians' perceptions of decision making regarding discharge from public hospitals to in-patient rehabilitation following trauma.

PubMed

Kimmel, Lara A; Holland, Anne E; Lannin, Natasha; Edwards, Elton R; Page, Richard S; Bucknill, Andrew; Hau, Raphael; Gabbe, Belinda J

2017-05-01

Objective The aim of the present study was to investigate the perceptions of consultant surgeons, allied health clinicians and rehabilitation consultants regarding discharge destination decision making from the acute hospital following trauma. Methods A qualitative study was performed using individual in-depth interviews of clinicians in Victoria (Australia) between April 2013 and September 2014. Thematic analysis was used to derive important themes. Case studies provided quantitative information to enhance the information gained via interviews. Results Thirteen rehabilitation consultants, eight consultant surgeons and 13 allied health clinicians were interviewed. Key themes that emerged included the importance of financial considerations as drivers of decision making and the perceived lack of involvement of medical staff in decisions regarding discharge destination following trauma. Other themes included the lack of consistency of factors thought to be important drivers of discharge and the difficulty in acting on trauma patients' requests in terms of discharge destination. Importantly, as the complexity of the patient increases in terms of acquired brain injury, the options for rehabilitation become scarcer. Conclusions The information gained in the present study highlights the large variation in discharge practises between and within clinical groups. Further consultation with stakeholders involved in the care of trauma patients, as well as government bodies involved in hospital funding, is needed to derive a more consistent approach to discharge destination decision making. What is known about the topic? Little is known about the drivers for referral to, or acceptance at, in-patient rehabilitation following acute hospital care for traumatic injury in Victoria, Australia, including who makes these decisions of behalf of patients and how these decisions are made. What does this paper add? This paper provides information regarding the perceptions of acute hospital consultant surgeons and allied health, as well as rehabilitation clinicians, in terms of discharge destination decision making from the acute hospital following trauma. The use of case studies further highlights differences between, and within, these specialities with regard to this decision making. This research also highlights the importance of financial considerations as drivers of decision making, and the lack of consistency of the factors thought to be important drivers of discharge between these different clinical groupings. What are the implications for practitioners? This research shows that financial factors are significant drivers of discharge destination decision making for trauma patients. The present study highlights opportunities to engage with stakeholders (acute care, rehabilitation, administration, government and patients) to develop more consistent discharge processes that optimise the use of rehabilitation resources for those patients who could benefit from in-patient rehabilitation.

Consultation audio-recording reduces long-term decision regret after prostate cancer treatment: A non-randomised comparative cohort study.

PubMed

Good, Daniel W; Delaney, Harry; Laird, Alexander; Hacking, Belinda; Stewart, Grant D; McNeill, S Alan

2016-12-01

The life expectancy of prostate patients is long and patients will spend many years carrying the burdens & benefits of the treatment decisions they have made, therefore, it is vital that decisions on treatments are shared between patient and physician. The objective was to determine if consultation audio-recording improves quality of life, reduces regret or improves patient satisfaction in comparison to standard counselling. In 2012 we initiated consultation audio-recordings, where patients are given a CD of their consultation to keep and replay at home. We conducted a prospective non-randomised study of patient satisfaction, quality of life (QOL) and decision regret at 12 months follow-up using posted validated questionnaires for the audio-recording (AR) patients and a control cohort. Qualitative and thematic analyses were used. Forty of 59 patients in the AR group, and 27 of 45 patients in the control group returned the questionnaires. Patient demographics were similar in both groups with no statistically significant differences between the two groups. Decision regret was lower in the audio-recording group (11/100) vs control group (19/100) (p = 0.04). The risk ratio for not having any long-term decision regret was 5.539 (CI 1.643-18.674), with NNT to prevent regret being 4. Regression analysis showed that receiving audio-recording was strongest predictor for absence of regret even greater than potency and incontinence. The study has shown that audio-recording clinic consultation reduces long-term decision regret, increases patient information recall, understanding and confidence in their decision. There is great potential for further expansion of this low-cost intervention. Copyright © 2014 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.

Measuring shared decision making in the consultation: a comparison of the OPTION and Informed Decision Making instruments.

PubMed

Weiss, Marjorie C; Peters, Tim J

2008-01-01

To investigate the applied and conceptual relationship between two measures of shared decision making using the OPTION instrument developed in Wales and the Informed Decision Making instrument developed in Seattle, USA using audio-taped consultation data from a UK general practice population. Twelve general practitioners were recruited from 6 general practices in the southwest of England. One hundred twenty-three GP-patient consultations were audio-recorded. Audiotapes were sent off to, and rated by, respective experts in the use of the OPTION and the Informed Decision Making instruments. Compared to earlier work using the Informed Decision Making tool, consultations in this sample were shorter, had fewer decisions and tended to have a greater number of elements present. Similar to previous research using the OPTION, values using the OPTION instrument were low with two items, giving the patient opportunities to ask questions and checking patient understanding, exhibiting the most variability. Using a 'key' decision in each consultation as the basis for comparison, the Informed Decision Making score was not related to the overall OPTION score (Spearman's rho=0.14, p=0.13). Both instruments also predicted different 'best' and 'worst' doctors. Using a Bland-Altman plot for assessing agreement, the mean difference between the two measures was 1.11 (CI 0.66-1.56) and the limits of agreement were -3.94 to 6.16. There were several elements between the two instruments that appeared conceptually similar and correlations for these were generally higher. These were: discussing alternatives or options (Spearman's rho=0.35, p=0.0001), discussion of the patient's role in decision making (Spearman's rho=0.23, p=0.012), discussion of the pros/cons of the alternatives (Spearman's rho=0.20, p=0.024) and assessment of the patient's understanding (Spearman's rho=0.19, p=0.03). Measures of shared decision making are helpful in identifying those shared decision making skills which may be problematic or difficult to integrate into practice and provide a tool by which the development of skills can be assessed over time. Research may implicitly place undue value on those aspects of shared decision making which are most easily measured. Shared decision making tools are a useful way of capturing the presence or absence of specific shared decision making skills and changes in skills acquisition over time. However there may be limits in the extent to which the concept of shared decision making can be measured and that more easily measured skills will be emphasised to the detriment of other important shared decision making skills.

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

PubMed

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

2018-01-01

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

On Decision-Making Among Multiple Rule-Bases in Fuzzy Control Systems

NASA Technical Reports Server (NTRS)

Tunstel, Edward; Jamshidi, Mo

1997-01-01

Intelligent control of complex multi-variable systems can be a challenge for single fuzzy rule-based controllers. This class of problems cam often be managed with less difficulty by distributing intelligent decision-making amongst a collection of rule-bases. Such an approach requires that a mechanism be chosen to ensure goal-oriented interaction between the multiple rule-bases. In this paper, a hierarchical rule-based approach is described. Decision-making mechanisms based on generalized concepts from single-rule-based fuzzy control are described. Finally, the effects of different aggregation operators on multi-rule-base decision-making are examined in a navigation control problem for mobile robots.

76 FR 27859 - 8(a) Business Development Program Regulation Changes; Tribal Consultation

Federal Register 2010, 2011, 2012, 2013, 2014

2011-05-13

... SMALL BUSINESS ADMINISTRATION 13 CFR Part 124 [Docket No.: SBA-2011-0013] 8(a) Business Development Program Regulation Changes; Tribal Consultation AGENCY: U.S. Small Business Administration. ACTION.... Small Business Administration (SBA or Agency) published a final rule in the Federal Register making...

A three-talk model for shared decision making: multistage consultation process

PubMed Central

Durand, Marie Anne; Song, Julia; Aarts, Johanna; Barr, Paul J; Berger, Zackary; Cochran, Nan; Frosch, Dominick; Galasiński, Dariusz; Gulbrandsen, Pål; Han, Paul K J; Härter, Martin; Kinnersley, Paul; Lloyd, Amy; Mishra, Manish; Perestelo-Perez, Lilisbeth; Scholl, Isabelle; Tomori, Kounosuke; Trevena, Lyndal; Witteman, Holly O; Van der Weijden, Trudy

2017-01-01

Objectives To revise an existing three-talk model for learning how to achieve shared decision making, and to consult with relevant stakeholders to update and obtain wider engagement. Design Multistage consultation process. Setting Key informant group, communities of interest, and survey of clinical specialties. Participants 19 key informants, 153 member responses from multiple communities of interest, and 316 responses to an online survey from medically qualified clinicians from six specialties. Results After extended consultation over three iterations, we revised the three-talk model by making changes to one talk category, adding the need to elicit patient goals, providing a clear set of tasks for each talk category, and adding suggested scripts to illustrate each step. A new three-talk model of shared decision making is proposed, based on “team talk,” “option talk,” and “decision talk,” to depict a process of collaboration and deliberation. Team talk places emphasis on the need to provide support to patients when they are made aware of choices, and to elicit their goals as a means of guiding decision making processes. Option talk refers to the task of comparing alternatives, using risk communication principles. Decision talk refers to the task of arriving at decisions that reflect the informed preferences of patients, guided by the experience and expertise of health professionals. Conclusions The revised three-talk model of shared decision making depicts conversational steps, initiated by providing support when introducing options, followed by strategies to compare and discuss trade-offs, before deliberation based on informed preferences. PMID:29109079

Decision-making on shared sanitation in the informal settlements of Kisumu, Kenya.

PubMed

Simiyu, Sheillah; Swilling, Mark; Cairncross, Sandy

2017-10-01

Unlike most quantitative studies that investigate decision-making on investing in sanitation, this study adopted a qualitative approach to investigate decision-making on shared sanitation in the informal settlements of Kisumu city, in Kenya. Using a grounded theory approach, landlords and tenants were interviewed to identify sanitation decisions, individuals involved in decision-making and factors influencing decision-making. The results indicate that the main sanitation decisions are on investment, emptying, repair and cleaning. Landlords make investment, emptying and repair decisions, while tenants make cleaning decisions. Absentee landlords are less involved in most decision-making compared to live-in landlords, who rarely consult tenants in decision-making. Tenants make decisions after consultations with a third party and often collectively with other tenants. Sanitation interventions in informal settlements should thus, target landlords and tenants, with investment efforts being directed at landlords and maintenance efforts at tenants.

The role of the bioethicist in family meetings about end of life care.

PubMed

Watkins, Liza T; Sacajiu, Galit; Karasz, Alison

2007-12-01

There has been little study of the content of bioethicists' communication during family meeting consultations about end of life care. In the literature, two roles for bioethicists are usually described: the "consultant" role, in which bioethicists define and support ethical principles such as those enshrined in the "rational choice" model; and the "mediator" role, which focuses on the enhancement of communication in order to reduce conflict. In this study, we use observational data to explore how bioethicists support the practice of decision making during family meetings about end of life care. In a study conducted in the Bronx, New York, USA, researchers observed and recorded 24 decision-making meetings between hospital staff and family members of elderly patients identified as being in the last stages of illness, who were unable or unwilling to make the decision for themselves. Bioethics consultants were present during five of those meetings. Although bioethicists referred to the "rational choice" decision-making hierarchy, we did not see the systematic exploration described in the literature. Rather, our data show that bioethicists tended to employ elements of the rational model at particular turning points in the decision-making process in order to achieve pragmatic goals. As mediators, bioethicists worked to create consensus between family and staff and provided invaluable sympathy and comfort to distressed family members. We also found evidence of a context-dependent approach to mediation, with bioethicists' contributions generally supporting staff views about end of life care. Bioethicists' called to consult on family meetings about end of life care do not appear to adhere to a strict interpretation of the official guidelines. In order to negotiate the difficult terrain of end of life decision making, our data show that bioethicists often add a third role, "persuader", to official roles of "consultant" and "mediator".

How Effective Is a Virtual Consultation Process in Facilitating Multidisciplinary Decision-Making for Malignant Epidural Spinal Cord Compression?

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

Fitzpatrick, David; St Luke's Hospital, Dublin; Grabarz, Daniel

Purpose: The purpose of this study was to assess the accuracy of a virtual consultation (VC) process in determining treatment strategy for patients with malignant epidural spinal cord compression (MESCC). Methods and Materials: A prospective clinical database was maintained for patients with MESCC. A virtual consultation process (involving exchange of key predetermined clinical information and diagnostic imaging) facilitated rapid decision-making between oncologists and spinal surgeons. Diagnostic imaging was reviewed retrospectively (by R.R.) for surgical opinions in all patients. The primary outcome was the accuracy of virtual consultation opinion in predicting the final treatment recommendation. Results: After excluding 20 patients whomore » were referred directly to the spinal surgeon, 125 patients were eligible for virtual consultation. Of the 46 patients who had a VC, surgery was recommended in 28 patients and actually given to 23. A retrospective review revealed that 5/79 patients who did not have a VC would have been considered surgical candidates. The overall accuracy of the virtual consultation process was estimated at 92%. Conclusion: The VC process for MESCC patients provides a reliable means of arriving at a multidisciplinary opinion while minimizing patient transfer. This can potentially shorten treatment decision time and enhance clinical outcomes.« less

46 CFR 201.3 - Authentication of rules, orders, determinations and decisions of the Administration.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 46 Shipping 8 2010-10-01 2010-10-01 false Authentication of rules, orders, determinations and decisions of the Administration. 201.3 Section 201.3 Shipping MARITIME ADMINISTRATION, DEPARTMENT OF....3 Authentication of rules, orders, determinations and decisions of the Administration. All rules...

48 CFR 9.505 - General rules.

Code of Federal Regulations, 2010 CFR

2010-10-01

... CONTRACTOR QUALIFICATIONS Organizational and Consultant Conflicts of Interest 9.505 General rules. The..., neutralizing, or mitigating organizational conflicts of interest that might otherwise exist in the stated situations. Some illustrative examples are provided in 9.508. Conflicts may arise in situations not expressly...

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

PubMed

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

2017-04-01

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

Better Decisions through Consultation and Collaboration

EPA Pesticide Factsheets

This manual discusses the benefits of public involvement to agency decision makers, including expanding shared baseline knowledge, generating support for the decision, and developing ongoing relationships that will help in implementing decisions.

48 CFR 6103.306 - Decisions [Rule 306].

Code of Federal Regulations, 2010 CFR

2010-10-01

... 48 Federal Acquisition Regulations System 7 2010-10-01 2010-10-01 false Decisions [Rule 306]. 6103.306 Section 6103.306 Federal Acquisition Regulations System CIVILIAN BOARD OF CONTRACT APPEALS, GENERAL SERVICES ADMINISTRATION TRANSPORTATION RATE CASES 6103.306 Decisions [Rule 306]. The judge will issue a written decision based upon the record,...

Experiences of using email for general practice consultations: a qualitative study.

PubMed

Atherton, Helen; Pappas, Yannis; Heneghan, Carl; Murray, Elizabeth

2013-11-01

Reports suggest approximately 21-23% of GPs in the UK have consulted with patients using email, but little is known about the nature of this use and what it means for clinicians and patients in general practice. To understand the use of email consultation in general practice by investigating the experiences of existing users and views of experts. A qualitative study conducted in 2010 using purposive sampling and semi-structured interviews in general practice and community settings in some London boroughs. A maximum variation sample of GPs and patients who had used email for consultation in general practice were recruited, as were policy and/or implementation experts. Interviews continued until saturation was achieved. In total 10 GPs, 14 patients, and six experts were interviewed. Consultation by email was often triggered by logistic or practical issues; motivators for ongoing use were the benefits, such as convenience, for GPs and patients. Both GPs and patients reported concerns about safety and lack of guidance about the 'rules of engagement' in email consultations, with GPs also concerned about workload. In response, both groups attempted to introduce their own rules, although this only went some way to addressing uncertainty. Long term, participants felt there was a need for regulation and guidance. Consultations by email in general practice occur in an unregulated and unstructured way. Current UK policy is to promote consultations by email, making it crucial to consider the responsibility and workload faced by clinicians, and the changes required to ensure safe use; not doing so may risk safety breaches and result in suboptimal care for patients.

Calling the Doctor: A Qualitative Study of Patient-Initiated Physician Consultation among rural older adults

PubMed Central

Grzywacz, Joseph G.; Quandt, Sara A.; Bell, Ronny A.; Chapman, Christine; Altizer, Kathryn P.; Arcury, Thomas A.

2011-01-01

Objectives Guided by Leventhal’s Self-regulatory Model and Cockerham’s theory of health lifestyles, we explore 2 questions regarding physician consultation among elderly rural adults: What symptom characteristics prompt patient-initiated physician consultation? Do participants’ accounts of responses to symptoms, including the decision to consult a physician, incorporate descriptions of change over time? Methods We analyze data from semi-structured in-depth interviews with 62 older rural adults. Results Accounts of decisions to initiate contact with physicians support prior research. Some symptoms encouraged immediate consultation; others prompted periods of monitoring and lay management. Physicians were most often contacted if changes were new, unusually severe, persisted or worsened, or failed to respond to lay treatment. Discussion We characterize participants’ responses to symptoms as bricolages to highlight their construction from available materials. Incorporating the integrating concept of bricolage and Cockerham’s emphasis on both general dispositions and symptom-specific responses represents an important extension of Leventhal’s conceptualization of illness behavior, including patient-initiated physician consultation. PMID:21311048

Calling the doctor: a qualitative study of patient-initiated physician consultation among rural older adults.

PubMed

Stoller, Eleanor Palo; Grzywacz, Joseph G; Quandt, Sara A; Bell, Ronny A; Chapman, Christine; Altizer, Kathryn P; Arcury, Thomas A

2011-08-01

Guided by Leventhal's self-regulatory model and Cockerham's theory of health lifestyles, we explore two questions regarding physician consultation among elderly rural adults: What symptom characteristics prompt patient-initiated physician consultation? Do participants' accounts of responses to symptoms, including the decision to consult a physician, incorporate descriptions of change over time? We analyze data from semistructured in-depth interviews with 62 older rural adults. Accounts of decisions to initiate contact with physicians support prior research. Some symptoms encouraged immediate consultation; others prompted periods of monitoring and lay management. Physicians were most often contacted if changes were new, unusually severe, persisted or worsened, or failed to respond to lay treatment. We characterize participants' responses to symptoms as bricolages to highlight their construction from available materials. Incorporating the integrating concept of bricolage and Cockerham's emphasis on both general dispositions and symptom-specific responses represents an important extension of Leventhal's conceptualization of illness behavior, including patient-initiated physician consultation.

Bayesian design of decision rules for failure detection

NASA Technical Reports Server (NTRS)

Chow, E. Y.; Willsky, A. S.

1984-01-01

The formulation of the decision making process of a failure detection algorithm as a Bayes sequential decision problem provides a simple conceptualization of the decision rule design problem. As the optimal Bayes rule is not computable, a methodology that is based on the Bayesian approach and aimed at a reduced computational requirement is developed for designing suboptimal rules. A numerical algorithm is constructed to facilitate the design and performance evaluation of these suboptimal rules. The result of applying this design methodology to an example shows that this approach is potentially a useful one.

20 CFR 404.1519a - When we will purchase a consultative examination and how we will use it.

Code of Federal Regulations, 2010 CFR

2010-04-01

... Disability Determinations § 404.1519a When we will purchase a consultative examination and how we will use it. (a)(1) General. The decision to purchase a consultative examination for you will be made after we... 20 Employees' Benefits 2 2010-04-01 2010-04-01 false When we will purchase a consultative...

20 CFR 416.919a - When we will purchase a consultative examination and how we will use it.

Code of Federal Regulations, 2010 CFR

2010-04-01

... with Disability Determinations § 416.919a When we will purchase a consultative examination and how we will use it. (a)(1) General. The decision to purchase a consultative examination for you will be made... 20 Employees' Benefits 2 2010-04-01 2010-04-01 false When we will purchase a consultative...

20 CFR 220.53 - When the Board will purchase a consultative examination and how it will be used.

Code of Federal Regulations, 2010 CFR

2010-04-01

... the Board will purchase a consultative examination and how it will be used. (a)(1) General. The decision to purchase a consultative examination for a claimant will be made after full consideration is... 20 Employees' Benefits 1 2010-04-01 2010-04-01 false When the Board will purchase a consultative...

Children's participation in consultations and decision-making at health service level: a review of the literature.

PubMed

Coyne, Imelda

2008-11-01

The past decade has seen a growing recognition in Ireland and internationally that children and young people have a right to participate in matters that affect their lives. To critique the research literature on children's, parents and healthcare professionals' experiences of children's participation in consultations and decision-making within the healthcare setting. The literature was obtained from electronic databases, books, and journals focusing on work published in between 1993 and 2007. Despite the importance of consulting with sick children, their views are rarely sought nor acknowledged within the healthcare setting. Children are rarely involved in decision-making process and appear to occupy a marginalized position in healthcare encounters. Healthcare professionals and parents play a significant influence on whether children's efforts to participate are facilitated and supported in the hospital setting. There is a need for further research to explore health professionals' and parents' perspectives on children's participation in consultations and decision-making, as clearly they have reservations/concerns about children's active involvement in such matters. This information could be used to develop guidelines that will assist professionals and parents in facilitating and supporting children's participation.

77 FR 43520 - Significant New Use Rules on a Certain Chemical Substance; Removal of Significant New Use Rules

Federal Register 2010, 2011, 2012, 2013, 2014

2012-07-25

... April 27, 2012 (77 FR 25236) (FRL-9343-4). If you have questions regarding the applicability of this... (77 FR 25236). If you have questions, consult the technical person listed under FOR FURTHER... 2070-AB27 Significant New Use Rules on a Certain Chemical Substance; Removal of Significant New Use...

Extension of the Expiration Date for State Disability Examiner Authority To Make Fully Favorable Quick Disability Determinations and Compassionate Allowance Determinations. Final rule.

PubMed

2016-10-24

We are extending, until December 28, 2018, the expiration date of our disability examiner authority (DEA) rule, which authorizes State agency disability examiners to make fully favorable determinations without the approval of a State agency medical or psychological consultant in claims that we consider under our quick disability determination (QDD) and compassionate allowance (CAL) processes. This is our last extension of this rule because we will phase out the use of DEA during the extension period under section 832 of the Bipartisan Budget Act of 2015 (BBA). This extension provides us the time necessary to take all of the administrative actions we need to take in order to reinstate uniform use of medical and psychological consultants. The current rule will expire on November 11, 2016. In this final rule, we are changing the November 11, 2016 expiration or "sunset" date to December 28, 2018, extending the authority for 2 years and 1 month. This is the final extension of our DEA rule. On December 28, 2018, at the conclusion of this extension, the authority for this test will terminate. We are making no other changes.

Testing the feasibility, acceptability and effectiveness of a 'decision navigation' intervention for early stage prostate cancer patients in Scotland--a randomised controlled trial.

PubMed

Hacking, Belinda; Wallace, Louise; Scott, Sarah; Kosmala-Anderson, Joanna; Belkora, Jeffrey; McNeill, Alan

2013-05-01

Does decision navigation (DN) increase prostate cancer patients' confidence and certainty in treatment decisions, while reducing regret associated with the decisions made? Two hundred eighty-nine newly diagnosed prostate cancer patients were eligible. 123 consented and were randomised to usual care (n = 60) or navigation (n = 63). The intervention involved a 'navigator' guiding the patient in creating a personal question list for a consultation and providing a CD and typed summary of the consultation to patients, the general practitioner and physician. The primary outcome was decisional self efficacy. Secondary outcomes included decisional conflict (DCS) and decisional regret (RS). Measures of mood (Hospital Anxiety and Depression Scale) and adjustment (Mental Adjustment to Cancer Scale) were included to detect potential adverse effects of the intervention. ANOVA showed a main effect for the group (F = 7.161, df 1, p = 0.009). Post hoc comparisons showed significantly higher decisional self efficacy in the navigated patients post-consultation and 6 months later. Decisional conflict was lower for navigated patients initially (t = 2.005, df = 105, p = 0.047), not at follow-up (t = 1.969, df = 109, p = 0.052). Regret scores were significantly lower in the navigation group compared to the controls 6 months later (t = -2.130, df = 100, p = 0.036). There was no impact of the intervention on mood or adjustment. Compared to control patients, navigated patients were more confident in making decisions about cancer treatment, were more certain they had made the right decision after the consultation and had less regret about their decision 6 months later. Decision navigation was feasible, acceptable and effective for newly diagnosed prostate cancer patients in Scotland. Copyright © 2012 John Wiley & Sons, Ltd.

A three-talk model for shared decision making: multistage consultation process.

PubMed

Elwyn, Glyn; Durand, Marie Anne; Song, Julia; Aarts, Johanna; Barr, Paul J; Berger, Zackary; Cochran, Nan; Frosch, Dominick; Galasiński, Dariusz; Gulbrandsen, Pål; Han, Paul K J; Härter, Martin; Kinnersley, Paul; Lloyd, Amy; Mishra, Manish; Perestelo-Perez, Lilisbeth; Scholl, Isabelle; Tomori, Kounosuke; Trevena, Lyndal; Witteman, Holly O; Van der Weijden, Trudy

2017-11-06

Objectives  To revise an existing three-talk model for learning how to achieve shared decision making, and to consult with relevant stakeholders to update and obtain wider engagement. Design  Multistage consultation process. Setting  Key informant group, communities of interest, and survey of clinical specialties. Participants  19 key informants, 153 member responses from multiple communities of interest, and 316 responses to an online survey from medically qualified clinicians from six specialties. Results  After extended consultation over three iterations, we revised the three-talk model by making changes to one talk category, adding the need to elicit patient goals, providing a clear set of tasks for each talk category, and adding suggested scripts to illustrate each step. A new three-talk model of shared decision making is proposed, based on "team talk," "option talk," and "decision talk," to depict a process of collaboration and deliberation. Team talk places emphasis on the need to provide support to patients when they are made aware of choices, and to elicit their goals as a means of guiding decision making processes. Option talk refers to the task of comparing alternatives, using risk communication principles. Decision talk refers to the task of arriving at decisions that reflect the informed preferences of patients, guided by the experience and expertise of health professionals. Conclusions  The revised three-talk model of shared decision making depicts conversational steps, initiated by providing support when introducing options, followed by strategies to compare and discuss trade-offs, before deliberation based on informed preferences. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Communication with patients and the duration of family medicine consultations.

PubMed

Valverde Bolívar, Francisco Javier; Pedregal González, Miguel; Moreno Martos, Herminia; Cózar García, Inmaculada; Torío Durántez, Jesús

2017-10-17

To determine the distribution of consultation times, the factors that determine their length, and their relationship with a more participative, patient-centred consulting style. Cross-sectional multicentre study. Primary Healthcare Centres in Andalusia, Spain. A total of 119 tutors and family medicine physician residents. Consultation length and communication with the patient were analysed using the CICCAA scale (Connect, Identify, Understand, Consent, Help) during 436 interviews in Primary Care. The mean duration of consultations was 8.8min (sd: 3.6). The consultation tended to be longer when the physician had a patient-centred approach (10.37±4.19min vs 7.54±2.98min; p=0.001), and when there was joint decision-making (9.79±3.96min vs 7.73±3.42min: p=0.001). In the multivariable model, longer consultations were associated with obtaining higher scores on the CICAA scale, a wider range of reasons for consultation, whether they came accompanied, in urban centres, and a smaller number of daily visits (r 2 =0.32). There was no correlation between physician or patient gender, or problem type. A more patient centred medical profile, increased shared decision-making, a wider range of reasons for consultation, whether they came accompanied, in urban centres, and less professional pressure all seem to be associated with a longer consultation. Copyright © 2017 Elsevier España, S.L.U. All rights reserved.

Patient and family communication during consultation visits: The effects of a decision aid for treatment decision-making for localized prostate cancer.

PubMed

Song, Lixin; Tyler, Christina; Clayton, Margaret F; Rodgiriguez-Rassi, Eleanor; Hill, Latorya; Bai, Jinbing; Pruthi, Raj; Bailey, Donald E

2017-02-01

To analyze the effects of a decision aid on improving patients' and family members' information giving and question asking during consultations for prostate cancer treatment decision-making. This study is a secondary analysis of archived audio-recorded real-time consultation visits with participants from a randomized clinical trial. Participants were randomly assigned into three groups: TD-intervention targeted patient-only; TS-intervention targeted patients and family members; and control-a handout on staying healthy during treatment. We conducted content analysis using a researcher-developed communication coding system. Using SAS 9.3, we conducted Chi-square/Fisher's exact test to examine whether information giving and question asking among patients and family members varied by groups when discussing different content/topics. Compared with those in the TS and control groups, significantly higher percentages of participants in the TD group demonstrated information giving in discussing topics about diagnosis, treatment options, risks and benefits, and preferences; and engaged in question asking when discussing diagnosis, watchful waiting/active surveillance, risks and benefits, and preferences for treatment impacts. Information support and communication skills training for patients were effective in improving communication during treatment decision-making consultations. Providing information about prostate cancer and communication skills training empower patients and their family members. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Patient and family communication during consultation visits: The effects of a decision aid for treatment decision-making for localized prostate cancer

PubMed Central

Song, Lixin; Tyler, Christina; Clayton, Margaret F.; Rodgiriguez-Rassi, Eleanor; Hill, Latorya; Bai, Jinbing; Pruthi, Raj; Bailey, Donald E.

2016-01-01

Objective To analyze the effects of a decision aid on improving patients’ and family members’ information giving and question asking during consultations for prostate cancer treatment decision-making. Methods This study is a secondary analysis of archived audio-recorded real-time consultation visits with participants from a randomized clinical trial. Participants were randomly assigned into three groups: TD—intervention targeted patient-only; TS—intervention targeted patients and family members; and control—a handout on staying healthy during treatment. We conducted content analysis using a researcher-developed communication coding system. Using SAS 9.3, we conducted Chi-square/Fisher’s exact test to examine whether information giving and question asking among patients and family members varied by groups when discussing different content/topics. Results Compared with those in the TS and control groups, significantly higher percentages of participants in the TD group demonstrated information giving in discussing topics about diagnosis, treatment options, risks and benefits, and preferences; and engaged in question asking when discussing diagnosis, watchful waiting/active surveillance, risks and benefits, and preferences for treatment impacts. Conclusion Information support and communication skills training for patients were effective in improving communication during treatment decision-making consultations. Practice implications Providing information about prostate cancer and communication skills training empower patients and their family members. PMID:27692491

A national survey of U.S. internists' experiences with ethical dilemmas and ethics consultation.

PubMed

DuVal, Gordon; Clarridge, Brian; Gensler, Gary; Danis, Marion

2004-03-01

To identify the ethical dilemmas that internists encounter, the strategies they use to address them, and the usefulness of ethics consultation. National telephone survey. Doctors' offices. General internists, oncologists, and critical care/pulmonologists (N = 344, 64% response rate). Types of ethical dilemmas recently encountered and likelihood of requesting ethics consultation; satisfaction with resolution of ethical dilemmas with and without ethics consultation. Internists most commonly reported dilemmas regarding end-of-life decision making, patient autonomy, justice, and conflict resolution. General internists, oncologists, and critical care specialists reported participating in an average of 1.4, 1.3, and 4.1 consultations in the preceding 2 years, respectively (P <.0001). Physicians with the least ethics training had the least access to and participated in the fewest ethics consultations; 19% reported consultation was unavailable at their predominant practice site. Dilemmas about end-of-life decisions and patient autonomy were often referred for consultation, while dilemmas about justice, such as lack of insurance or limited resources, were rarely referred. While most physicians thought consultations yielded information that would be useful in dealing with future ethical dilemmas (72%), some hesitated to seek ethics consultation because they believed it was too time consuming (29%), might make the situation worse (15%), or that consultants were unqualified (11%). While most internists recall recent ethical dilemmas in their practices, those with the least preparation and experience have the least access to ethics consultation. Health care organizations should emphasize ethics educational activities to prepare physicians for handling ethical dilemmas on their own and should improve the accessibility and responsiveness of ethics consultation when needed.

Testing decision rules for categorizing species' extinction risk to help develop quantitative listing criteria for the U.S. Endangered Species Act.

PubMed

Regan, Tracey J; Taylor, Barbara L; Thompson, Grant G; Cochrane, Jean Fitts; Ralls, Katherine; Runge, Michael C; Merrick, Richard

2013-08-01

Lack of guidance for interpreting the definitions of endangered and threatened in the U.S. Endangered Species Act (ESA) has resulted in case-by-case decision making leaving the process vulnerable to being considered arbitrary or capricious. Adopting quantitative decision rules would remedy this but requires the agency to specify the relative urgency concerning extinction events over time, cutoff risk values corresponding to different levels of protection, and the importance given to different types of listing errors. We tested the performance of 3 sets of decision rules that use alternative functions for weighting the relative urgency of future extinction events: a threshold rule set, which uses a decision rule of x% probability of extinction over y years; a concave rule set, where the relative importance of future extinction events declines exponentially over time; and a shoulder rule set that uses a sigmoid shape function, where relative importance declines slowly at first and then more rapidly. We obtained decision cutoffs by interviewing several biologists and then emulated the listing process with simulations that covered a range of extinction risks typical of ESA listing decisions. We evaluated performance of the decision rules under different data quantities and qualities on the basis of the relative importance of misclassification errors. Although there was little difference between the performance of alternative decision rules for correct listings, the distribution of misclassifications differed depending on the function used. Misclassifications for the threshold and concave listing criteria resulted in more overprotection errors, particularly as uncertainty increased, whereas errors for the shoulder listing criteria were more symmetrical. We developed and tested the framework for quantitative decision rules for listing species under the U.S. ESA. If policy values can be agreed on, use of this framework would improve the implementation of the ESA by increasing transparency and consistency. Conservation Biology © 2013 Society for Conservation Biology No claim to original US government works.

Taking on the doctor role in whole-task simulation.

PubMed

Bartlett, Maggie; Gay, Simon P; Kinston, Ruth; McKinley, Robert

2018-06-01

Untimed simulated primary care consultations focusing on safe and effective clinical outcomes were first introduced into undergraduate medical education in Otago, New Zealand, in 2004. We extended this concept and included a secondary care version for final-year students. We offer students opportunities to manage entire consultations, which include making and implementing clinical decisions with simulated patients (SPs). Formative feedback is given by SPs on the achievement of pre-determined outcomes and by faculty members on clinical decision making, medical record keeping and case presentation. We explored students' perceptions of the educational value of the sessions using post-session questionnaires (n = 194) and focus groups (n = 36 participants overall). Students are offered opportunities to manage entire consultations with simulated patients RESULTS: Students perceived that the sessions were useful, enjoyable and relevant to early postgraduate practice. They identified useful learning in time management, communication, decision making, prescribing and managing uncertainty. Students identified gaps in their knowledge and recognised that they had been offered opportunities to develop decision-making skills by having to take responsibility for whole consultations and all the decisions included within them. Most students reported positive impacts on learning, although a small minority reported negative impacts on their perceptions of their ability to cope as a junior doctor. These simulated consultation sessions appear to lead to the effective learning of a range of skills that students need in order to work as junior doctors. Facilitators leading such sessions must be alert to the possibility of educational harm arising from such simulations, and the need to address this during the debriefing. © 2017 John Wiley & Sons Ltd and The Association for the Study of Medical Education.

Psychiatric patient disposition agreement between the emergency physician and the psychiatry consultant.

PubMed

Chakravarthy, Bharath; Menchine, Michael; Thompson, Daniel E; Rajeev, Sindhya; Santos, Barbara-Jean

2013-01-01

Mental illness is prevalent, disabling, and costly. Emergency department (ED) visits for mental health-related reasons are on the increase. Determine the level of agreement between emergency physicians and psychiatrists regarding psychiatric patient disposition. We conducted a prospective, observational study at a private university hospital ED from October 2008-April 2009 using a convenience sample of patients of all ages with psychiatric complaints who received formal psychiatric consultation during their ED visit. The emergency physician completed a data sheet prior to psychiatric consultation, assessing the likelihood of admission for psychiatric evaluation. We evaluated the positive predictive value (PPV) and negative predictive value (NPV) of the emergency physician admission decision for all patients before psychiatric consultation, compared with the patients' actual disposition as determined by the consulting psychiatrist. The study captured 230 subjects, 53% of whom were suicidal patients. 74% of patients were eventually admitted. The emergency physician decision to admit for inpatient psychiatric evaluation had a PPV of 87.3% (CI 81.4-91.9%) and an NPV of 66.7% (CI 52.9-78.6%) compared to the psychiatrist decision for the total sample, and a PPV of 90% (CI 82.4-95.1%) and an NPV of 69.6% (CI 47.1-86.8%) for suicidal patients. Additionally, the κ score, a measure of agreement between emergency physician disposition decision and psychiatrist disposition decision, was 0.530 (Cl 0.404-0.656). 95% of patients with an ED assessment of "definitely admit" were eventually admitted by the psychiatrist. Emergency physician disposition has a high PPV (87.3%) and a moderate NPV (66.7%) compared to psychiatrist disposition.

What we talk about when we talk about depression: doctor-patient conversations and treatment decision outcomes

PubMed Central

Karasz, Alison; Dowrick, Christopher; Byng, Richard; Buszewicz, Marta; Ferri, Lucia; Hartman, Tim C Olde; van Dulmen, Sandra; van Weel-Baumgarten, Evelyn; Reeve, Joanne

2011-01-01

Background Efforts to address depression in primary care settings have focused on the introduction of care guidelines emphasising pharmacological treatment. To date, physician adherence remains low. Little is known of the types of information exchange or other negotiations in doctor-patient consultations about depression that influence physician decision making about treatment. Aim The study sought to understand conversational influences on physician decision making about treatment for depression. Design A secondary analysis of consultation data collected in other studies. Using a maximum variation sampling strategy, 30 transcripts of primary care consultations about distress or depression were selected from datasets collected in three countries. Transcripts were analysed to discover factors associated with prescription of medication. Method The study employed two qualitative analysis strategies: a micro-analysis approach, which examines how conversation partners shape the dialogue towards pragmatic goals; and a narrative analysis approach of the problem presentation. Results Patients communicated their conceptual representations of distress at the outset of each consultation. Concepts of depression were communicated through the narrative form of the problem presentation. Three types of narratives were identified: those emphasising symptoms, those emphasising life situations, and mixed narratives. Physician decision making regarding medication treatment was strongly associated with the form of the patient’s narrative. Physicians made few efforts to persuade patients to accept biomedical attributions or treatments. Conclusion Results of the study provide insight into why adherence to depression guidelines remains low. Data indicate that patient agendas drive the ‘action’ in consultations about depression. Physicians appear to be guided by common-sense decision-making algorithms emphasising patients’ views and preferences. PMID:22520683

Experiences of using email for general practice consultations: a qualitative study

PubMed Central

Atherton, Helen; Pappas, Yannis; Heneghan, Carl; Murray, Elizabeth

2013-01-01

Background Reports suggest approximately 21–23% of GPs in the UK have consulted with patients using email, but little is known about the nature of this use and what it means for clinicians and patients in general practice. Aim To understand the use of email consultation in general practice by investigating the experiences of existing users and views of experts. Design and setting A qualitative study conducted in 2010 using purposive sampling and semi-structured interviews in general practice and community settings in some London boroughs. Method A maximum variation sample of GPs and patients who had used email for consultation in general practice were recruited, as were policy and/or implementation experts. Interviews continued until saturation was achieved. Results In total 10 GPs, 14 patients, and six experts were interviewed. Consultation by email was often triggered by logistic or practical issues; motivators for ongoing use were the benefits, such as convenience, for GPs and patients. Both GPs and patients reported concerns about safety and lack of guidance about the ‘rules of engagement’ in email consultations, with GPs also concerned about workload. In response, both groups attempted to introduce their own rules, although this only went some way to addressing uncertainty. Long term, participants felt there was a need for regulation and guidance. Conclusion Consultations by email in general practice occur in an unregulated and unstructured way. Current UK policy is to promote consultations by email, making it crucial to consider the responsibility and workload faced by clinicians, and the changes required to ensure safe use; not doing so may risk safety breaches and result in suboptimal care for patients. PMID:24267859

The optimum decision rules for the oddity task.

PubMed

Versfeld, N J; Dai, H; Green, D M

1996-01-01

This paper presents the optimum decision rule for an m-interval oddity task in which m-1 intervals contain the same signal and one is different or odd. The optimum decision rule depends on the degree of correlation among observations. The present approach unifies the different strategies that occur with "roved" or "fixed" experiments (Macmillan & Creelman, 1991, p. 147). It is shown that the commonly used decision rule for an m-interval oddity task corresponds to the special case of highly correlated observations. However, as is also true for the same-different paradigm, there exists a different optimum decision rule when the observations are independent. The relation between the probability of a correct response and d' is derived for the three-interval oddity task. Tables are presented of this relation for the three-, four-, and five-interval oddity task. Finally, an experimental method is proposed that allows one to determine the decision rule used by the observer in an oddity experiment.

Decision-making competence in younger and older adults: which cognitive abilities contribute to the application of decision rules?

PubMed

Rosi, Alessia; Bruine de Bruin, Wändi; Del Missier, Fabio; Cavallini, Elena; Russo, Riccardo

2017-12-28

Older adults perform worse than younger adults when applying decision rules to choose between options that vary along multiple attributes. Although previous studies have shown that general fluid cognitive abilities contribute to the accurate application of decision rules, relatively little is known about which specific cognitive abilities play the most important role. We examined the independent roles of working memory, verbal fluency, semantic knowledge, and components of executive functioning. We found that age-related decline in applying decision rules was statistically mediated by age-related decline in working memory and verbal fluency. Our results have implications for theories of aging and decision-making.

[Dermatology day-care: between official rules and reality].

PubMed

Ingen-Housz-Oro, S; Durand-Zaleski, I; Cosnes, A; Valeyrie-Allanore, L; Moreno, J-C; Chosidow, O; Wolkenstein, P

2012-11-01

Official rules published in 2006 and 2010 concerning ambulatory care rates in France led to artificial redistribution of this activity from day-care hospitalization to consultations. In our dermatological day-care establishment, we compared the financial costs engendered for patients admitted for day-care hospitalization and those seen at consultations. From 2011/01/10 to 2011/02/04, for each patient, we prospectively analyzed the following data: day-care hospitalization or consultation, age, sex, diagnosis, laboratory and radiological examination, non-dermatological consultations, time spent with the patient by doctors (interns, senior doctors) and nurses, with timing by a stop-watch. The hospital cost was the total for medical examinations (official nomenclature), non-dermatological consultations, physicians' and nurses' salaries and establishment overheads (216 €). The hospital revenue regarding the consultation group consisted of the sum of reimbursement for medical examination, dermatological and non-dermatological consultations, and regarding the day-care hospitalization group, the dermatology rate (670 €) or chemotherapy sessions (380 €). Results were compared using a Chi(2) test and a Student's t-test (P ≤ 0.05). One hundred and twenty-seven patients were included: 67 in the day-care hospitalization group and 60 in the consultation group. Patients in the day-care hospitalization group were older and had significantly more radiological examinations and non-dermatological consultations, but the number of laboratory examinations and skin biopsies did not differ between the two groups. The mean time spent by doctors was similar in both groups but the time spent by senior doctors without the help of interns was significantly greater and longer than the time for a standard consultation. Nurses spent a mean 72 minutes with each hospitalized patient and 35 minutes with consultation patients (P = 0.007). Hospital costs were identical in both groups at around 415 €. The hospital showed a profit for day-care hospitalization patients (252 €) and a loss (244 €) for consultation patients. Half of the patients studied were in day-care hospitalization and half were seen in consultations. The high number of bed-ridden patients with bullous pemphigoid accounts for the fact that day-care patients were older. The reasons for the significantly longer time spent by nurses with day-care hospitalized patients were administration and supervision of chemotherapy, skin care and nursing of bed-ridden patients. However, nurses spent 35 min with each consultation patient, justifying the need to maintain the posts of these staff in such day-care units. The availability of physicians for patients with severe dermatoses and the organization of medical examinations in the same place in the same day underscore the need for medical structures like day-care hospitalization. At present, time spent on intellectual work involving reflection is regrettably not taken into account, which is detrimental to this specialty. The hospital was in profit for day hospitalizations while consultations resulted in losses, in particular because of the absence of social security reimbursement of the establishment's overheads. Rules are in need of modification in order to allow the treatment of patients with more complicated conditions. Copyright © 2012 Elsevier Masson SAS. All rights reserved.

Do Spaniards know their rights as patients?

PubMed

Mira, José Joaquín; Lorenzo, Susana; Guilabert, Mercedes; Pérez-Jover, Virtudes

2012-08-01

In 2002, Spain introduced new legislation regulating the rights of patients. Spaniards have thus seen an increase in their capacity for decision-making, bringing them into line with many other countries. However, the law changes do not mean to be acquainted with the new legislation and therefore, putting it into practice. To analyse whether the rules governing patients' rights in Spain are sufficiently well known among patients and to identify the profile of those patients most aware of their rights. Cross-sectional quota-sampled survey study. A total of 790 patients discharged from hospitals or attended in primary care took a telephone survey, 773 replayed. Twenty per cent had some knowledge of the rules governing patients' rights. Respondent characteristics that were associated with better knowledge of basic rights included: age of medical responsibility (P < 0.001), cases in which a doctor may inform family members (P < 0.001), whether or not a patient can refuse treatment (P < 0.001) and what is constituted by advance directives (P < 0.001). Patients who opt for a more active role in consultations with medical professionals show greater knowledge of their rights (P < 0.01). Age was related to greater ignorance of these rights (P < 0.01). Patients' knowledge of their rights is quite limited, making it difficult for them to assert those rights in specific medical encounters. The youngest patients, the most demanding, and those who prefer to have the last word in decisions are those with the best knowledge of their rights as patients.

Institutional policy learning and public consultation: the Canadian xenotransplantation experience.

PubMed

Jones, Mavis; Einsiedel, Edna

2011-09-01

Attempts to evaluate public consultations, participatory technology assessment, and deliberative democracy have typically considered impacts on either policy or participants. The determination of impacts on policy institutions has been limited due to the challenges of tracing effects through the policy process, or penetrating bureaucratic walls. This paper presents findings from a retrospective study exploring the institutional lessons learned from a 2001 Canadian national public consultation on xenotransplantation. The consultation was conducted through an arm's-length process and involved the use of citizen juries in six regional sites. We conducted in-depth interviews of regulatory and policy actors who were engaged in early policy discussions and the consultation process. We reviewed evaluations of this process, both internal and external, which gave us richer insights into what institutional actors saw as the impacts of this consultative experience on their policy environment. Participants in our research identified a broader shift toward openness in policy culture which they linked specifically to the innovative consultation process employed for xenotransplantation. We argue that beyond input into policy decisions, a consultation may have an impact in terms of its contribution to overall shifts in institutional culture (related to institutional learning), such as an "opening" of technological decision processes to a broader range of actors, knowledge, and values. Copyright © 2011 Elsevier Ltd. All rights reserved.

Requiem for the max rule?

PubMed Central

Ma, Wei Ji; Shen, Shan; Dziugaite, Gintare; van den Berg, Ronald

2015-01-01

In tasks such as visual search and change detection, a key question is how observers integrate noisy measurements from multiple locations to make a decision. Decision rules proposed to model this process haven fallen into two categories: Bayes-optimal (ideal observer) rules and ad-hoc rules. Among the latter, the maximum-of-outputs (max) rule has been most prominent. Reviewing recent work and performing new model comparisons across a range of paradigms, we find that in all cases except for one, the optimal rule describes human data as well as or better than every max rule either previously proposed or newly introduced here. This casts doubt on the utility of the max rule for understanding perceptual decision-making. PMID:25584425

A Decision Making Methodology in Support of the Business Rules Lifecycle

NASA Technical Reports Server (NTRS)

Wild, Christopher; Rosca, Daniela

1998-01-01

The business rules that underlie an enterprise emerge as a new category of system requirements that represent decisions about how to run the business, and which are characterized by their business-orientation and their propensity for change. In this report, we introduce a decision making methodology which addresses several aspects of the business rules lifecycle: acquisition, deployment and evolution. We describe a meta-model for representing business rules in terms of an enterprise model, and also a decision support submodel for reasoning about and deriving the rules. The possibility for lifecycle automated assistance is demonstrated in terms of the automatic extraction of business rules from the decision structure. A system based on the metamodel has been implemented, including the extraction algorithm. This is the final report for Daniela Rosca's PhD fellowship. It describes the work we have done over the past year, current research and the list of publications associated with her thesis topic.

77 FR 63763 - Regulatory Capital Rules: Standardized Approach for Risk-Weighted Assets; Market Discipline and...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-10-17

... BCBS in 2006 and 2009, as well as other proposals set forth in consultative papers of the BCBS. Section... provided in this Federal Register document, which describes the economic impact of the Standardized... in recent consultative papers of the BCBS.\\2\\ In the Standardized Approach NPR, the agencies also...

First Nations, Consultation, and the Rule of Law: Salmon Farming and Colonialism in British Columbia

ERIC Educational Resources Information Center

Schreiber, Dorothee

2006-01-01

Many coastal First Nations communities, particularly in British Columbia, see consultation as a positive way of getting around the firmly entrenched position of both provincial and federal governments on fish farming. Even those Native groups such as the Musgamagw Tsawataineuk Tribal Council (MTTC) and the Homalco First Nation, who are adamantly…

Comparison of ethical judgments exhibited by clients and ethics consultants in Japan

PubMed Central

2014-01-01

Background Healthcare professionals must make decisions for patients based on ethical considerations. However, they rely on clinical ethics consultations (CEC) to review ethical justifications of their decisions. CEC consultants support the cases reviewed and guide medical care. When both healthcare professionals and CEC consultants face ethical problems in medical care, how is their judgment derived? How do medical judgments differ from the ethical considerations of CECs? This study examines CECs in Japan to identify differences in the ethical judgment of clients and CEC consultants. Methods The CEC request and response documents of all 60 cases reviewed across Japan between October 2006 and the end of October 2011 were classified in terms of the presence of decisional capacity in the patient. We conducted a qualitative content analysis of the differences in reasoning between client and CEC consultants. Reasoned judgments were verified in individual cases to classify the similarities or differences of opinion between CEC clients and teams. Results As the result of classification of the decisional capacity and the difference of opinion regarding medical care, the most frequent category was 25 cases (41.7%) of “uncertain decisional capacity,” and 23 cases (38.3%) of “withholding of decision-making.” A chi-square analysis was performed on presence of decisional capacity and agreement in decision-making, yielding a statistically significant difference (p < 0.05). The CEC consultants’ reasoning was based on “patient’s preference was ambiguous,” “validity of family as a surrogate,” “estimation of patient preference,” and “patient’s best interest,” whereas the CEC client’s reasoning was based on “consistent family preference was shown/not shown” and “appropriate therapeutic methods to manage patient safety.” Conclusion Differences in opinions were found in cases classified according to decisional capacity. Furthermore, the reasoning behind judgments differed between CEC clients and CEC consultants. The reasoning of CEC consultants was critical and reflective, while for clients it was situational and pragmatic. PMID:24592932

Shared Decision Making and Other Variables as Correlates of Satisfaction with Health Care Decisions in a United States National Survey

PubMed Central

Wills, Celia E.; Holloman, Christopher; Olson, Jacklyn; Hechmer, Catherine; Miller, Carla K.; Duchemin, Anne-Marie

2012-01-01

Objective The purpose of this study was to examine the relationship between shared decision-making (SDM) and satisfaction with decision (SWD) within a larger survey of patient decision-making in health care consultations. Methods A randomly selected age-proportionate national sample of adults (aged 21–70 years) stratified on race, ethnicity, and gender (N = 488) was recruited from a health research volunteer registry and completed an online survey with reference to a recent health consultation. Measures included the Shared Decision Making-9 questionnaire (SDM-Q-9), Satisfaction With Decision (SWD) scale, sociodemographic, health, and other standardized decision-making measures. Forward selection weighted multiple regression analysis was used to model correlates of SWD. Results After controlling for sociodemographic variables, SDM-Q-9 total score was associated with SWD, adjusted R2 = .368, p < .001. Three of nine SDM-Q-9 items accounted for significant proportions of variance in SWD. Conclusion SDM was positively associated with SWD and was strongest for three areas of SDM: patients being helped in a health care consultation with understanding information, with treatment preference elicitation, and with weighing options thoroughly. Practice Implications By identifying variables such as SDM that are associated with SWD, health care interventions can better target modifiable factors to enhance satisfaction and other outcomes. PMID:22410642

Shared decision making and other variables as correlates of satisfaction with health care decisions in a United States national survey.

PubMed

Glass, Katherine Elizabeth; Wills, Celia E; Holloman, Christopher; Olson, Jacklyn; Hechmer, Catherine; Miller, Carla K; Duchemin, Anne-Marie

2012-07-01

The purpose of this study was to examine the relationship between shared decision-making (SDM) and satisfaction with decision (SWD) within a larger survey of patient decision-making in health care consultations. A randomly selected age-proportionate national sample of adults (aged 21-70 years) stratified on race, ethnicity, and gender (N=488) was recruited from a health research volunteer registry and completed an online survey with reference to a recent health consultation. Measures included the shared decision making-9 questionnaire (SDM-Q-9), Satisfaction With Decision (SWD) scale, sociodemographic, health, and other standardized decision-making measures. Forward selection weighted multiple regression analysis was used to model correlates of SWD. After controlling for sociodemographic variables, SDM-Q-9 total score was associated with SWD, adjusted R(2)=.368, p<.001. Three of nine SDM-Q-9 items accounted for significant proportions of variance in SWD. SDM was positively associated with SWD and was strongest for three areas of SDM: patients being helped in a health care consultation with understanding information, with treatment preference elicitation, and with weighing options thoroughly. By identifying variables such as SDM that are associated with SWD, health care interventions can better target modifiable factors to enhance satisfaction and other outcomes. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

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

PubMed Central

2016-01-01

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

Consultation with children in hospital: children, parents' and nurses' perspectives.

PubMed

Coyne, Imelda

2006-01-01

To explore children's, parents' and nurses' views on participation in care in the healthcare setting. Children have a right to be consulted and involved in their care. The grounded theory method was used and data were collected through in-depth interviews, questionnaires and observation. Sample consisted of 11 children, 10 parents and 12 nurses from four paediatric wards in two hospitals in England. Parents felt that children should be involved in the decision-making process thereby enhancing and promoting children's self-esteem and positive self-regard, which would consequently enhance their overall welfare. Likewise, children expressed the need for consultation and information so that they could understand their illness; be involved in their care, and prepare themselves for procedures. However, children's own opinions and views were underused and they had varying experiences of being consulted about their care and treatment. Nurses appeared to hold varying and discrepant views on the involvement of children in decisions and for some nurses, the child's involvement seemed to be dependent on the child's cognitive maturity and being defined as a rational subject. Health professionals' communication behaviour may reflect recognition of children's cognitive abilities rather than their competence to understand. The fact that children's nurses appeared to make decisions about involving children in decision making in the absence of a reliable framework was a significant finding and highlights a real problem in the current climate. Nurses faced with workforce pressures may encounter considerable challenges to facilitating children's involvement in decisions about their care. Hence it is imperative that nurses' examine the basis of their decisions and use more explicit criteria for determining children's involvement.

Decision tables and rule engines in organ allocation systems for optimal transparency and flexibility.

PubMed

Schaafsma, Murk; van der Deijl, Wilfred; Smits, Jacqueline M; Rahmel, Axel O; de Vries Robbé, Pieter F; Hoitsma, Andries J

2011-05-01

Organ allocation systems have become complex and difficult to comprehend. We introduced decision tables to specify the rules of allocation systems for different organs. A rule engine with decision tables as input was tested for the Kidney Allocation System (ETKAS). We compared this rule engine with the currently used ETKAS by running 11,000 historical match runs and by running the rule engine in parallel with the ETKAS on our allocation system. Decision tables were easy to implement and successful in verifying correctness, completeness, and consistency. The outcomes of the 11,000 historical matches in the rule engine and the ETKAS were exactly the same. Running the rule engine simultaneously in parallel and in real time with the ETKAS also produced no differences. Specifying organ allocation rules in decision tables is already a great step forward in enhancing the clarity of the systems. Yet, using these tables as rule engine input for matches optimizes the flexibility, simplicity and clarity of the whole process, from specification to the performed matches, and in addition this new method allows well controlled simulations. © 2011 The Authors. Transplant International © 2011 European Society for Organ Transplantation.

18 CFR 12.38 - Time for inspections and reports.

Code of Federal Regulations, 2010 CFR

2010-04-01

... PROJECT WORKS Inspection by Independent Consultant § 12.38 Time for inspections and reports. (a) General rule. After the initial inspection and report under this subpart for a project development, a new... before March 1, 1981 in compliance with the Commission's rules then in effect is deemed to fulfill the...

38 CFR 20.1303 - Rule 1303. Nonprecedential nature of Board decisions.

Code of Federal Regulations, 2010 CFR

2010-07-01

... 38 Pensions, Bonuses, and Veterans' Relief 2 2010-07-01 2010-07-01 false Rule 1303. Nonprecedential nature of Board decisions. 20.1303 Section 20.1303 Pensions, Bonuses, and Veterans' Relief....1303 Rule 1303. Nonprecedential nature of Board decisions. Although the Board strives for consistency...

38 CFR 20.1303 - Rule 1303. Nonprecedential nature of Board decisions.

Code of Federal Regulations, 2011 CFR

2011-07-01

... 38 Pensions, Bonuses, and Veterans' Relief 2 2011-07-01 2011-07-01 false Rule 1303. Nonprecedential nature of Board decisions. 20.1303 Section 20.1303 Pensions, Bonuses, and Veterans' Relief....1303 Rule 1303. Nonprecedential nature of Board decisions. Although the Board strives for consistency...

38 CFR 20.1303 - Rule 1303. Nonprecedential nature of Board decisions.

Code of Federal Regulations, 2013 CFR

2013-07-01

... 38 Pensions, Bonuses, and Veterans' Relief 2 2013-07-01 2013-07-01 false Rule 1303. Nonprecedential nature of Board decisions. 20.1303 Section 20.1303 Pensions, Bonuses, and Veterans' Relief....1303 Rule 1303. Nonprecedential nature of Board decisions. Although the Board strives for consistency...

38 CFR 20.1303 - Rule 1303. Nonprecedential nature of Board decisions.

Code of Federal Regulations, 2014 CFR

2014-07-01

... 38 Pensions, Bonuses, and Veterans' Relief 2 2014-07-01 2014-07-01 false Rule 1303. Nonprecedential nature of Board decisions. 20.1303 Section 20.1303 Pensions, Bonuses, and Veterans' Relief....1303 Rule 1303. Nonprecedential nature of Board decisions. Although the Board strives for consistency...

38 CFR 20.1303 - Rule 1303. Nonprecedential nature of Board decisions.

Code of Federal Regulations, 2012 CFR

2012-07-01

... 38 Pensions, Bonuses, and Veterans' Relief 2 2012-07-01 2012-07-01 false Rule 1303. Nonprecedential nature of Board decisions. 20.1303 Section 20.1303 Pensions, Bonuses, and Veterans' Relief....1303 Rule 1303. Nonprecedential nature of Board decisions. Although the Board strives for consistency...

19 CFR 177.10 - Publication of decisions.

Code of Federal Regulations, 2014 CFR

2014-04-01

... 19 Customs Duties 2 2014-04-01 2014-04-01 false Publication of decisions. 177.10 Section 177.10... TREASURY (CONTINUED) ADMINISTRATIVE RULINGS General Ruling Procedure § 177.10 Publication of decisions. (a....8(a)(3). (b) [Reserved] (c) Changes of practice. Before the publication of a ruling which has the...

Economic Evaluation of Pediatric Telemedicine Consultations to Rural Emergency Departments.

PubMed

Yang, Nikki H; Dharmar, Madan; Yoo, Byung-Kwang; Leigh, J Paul; Kuppermann, Nathan; Romano, Patrick S; Nesbitt, Thomas S; Marcin, James P

2015-08-01

Comprehensive economic evaluations have not been conducted on telemedicine consultations to children in rural emergency departments (EDs). We conducted an economic evaluation to estimate the cost, effectiveness, and return on investment (ROI) of telemedicine consultations provided to health care providers of acutely ill and injured children in rural EDs compared with telephone consultations from a health care payer prospective. We built a decision model with parameters from primary programmatic data, national data, and the literature. We performed a base-case cost-effectiveness analysis (CEA), a probabilistic CEA with Monte Carlo simulation, and ROI estimation when CEA suggested cost-saving. The CEA was based on program effectiveness, derived from transfer decisions following telemedicine and telephone consultations. The average cost for a telemedicine consultation was $3641 per child/ED/year in 2013 US dollars. Telemedicine consultations resulted in 31% fewer patient transfers compared with telephone consultations and a cost reduction of $4662 per child/ED/year. Our probabilistic CEA demonstrated telemedicine consultations were less costly than telephone consultations in 57% of simulation iterations. The ROI was calculated to be 1.28 ($4662/$3641) from the base-case analysis and estimated to be 1.96 from the probabilistic analysis, suggesting a $1.96 return for each dollar invested in telemedicine. Treating 10 acutely ill and injured children at each rural ED with telemedicine resulted in an annual cost-savings of $46,620 per ED. Telephone and telemedicine consultations were not randomly assigned, potentially resulting in biased results. From a health care payer perspective, telemedicine consultations to health care providers of acutely ill and injured children presenting to rural EDs are cost-saving (base-case and more than half of Monte Carlo simulation iterations) or cost-effective compared with telephone consultations. © The Author(s) 2015.

A National Survey of U.S. Internists’ Experiences with Ethical Dilemmas and Ethics Consultation

PubMed Central

DuVal, Gordon; Clarridge, Brian; Gensler, Gary; Danis, Marion

2004-01-01

OBJECTIVE To identify the ethical dilemmas that internists encounter, the strategies they use to address them, and the usefulness of ethics consultation. DESIGN National telephone survey. SETTING Doctors’ offices. PARTICIPANTS General internists, oncologists, and critical care/pulmonologists (N = 344, 64% response rate). MEASUREMENTS Types of ethical dilemmas recently encountered and likelihood of requesting ethics consultation; satisfaction with resolution of ethical dilemmas with and without ethics consultation. RESULTS Internists most commonly reported dilemmas regarding end-of-life decision making, patient autonomy, justice, and conflict resolution. General internists, oncologists, and critical care specialists reported participating in an average of 1.4, 1.3, and 4.1 consultations in the preceding 2 years, respectively (P < .0001). Physicians with the least ethics training had the least access to and participated in the fewest ethics consultations; 19% reported consultation was unavailable at their predominant practice site. Dilemmas about end-of-life decisions and patient autonomy were often referred for consultation, while dilemmas about justice, such as lack of insurance or limited resources, were rarely referred. While most physicians thought consultations yielded information that would be useful in dealing with future ethical dilemmas (72%), some hesitated to seek ethics consultation because they believed it was too time consuming (29%), might make the situation worse (15%), or that consultants were unqualified (11%). CONCLUSIONS While most internists recall recent ethical dilemmas in their practices, those with the least preparation and experience have the least access to ethics consultation. Health care organizations should emphasize ethics educational activities to prepare physicians for handling ethical dilemmas on their own and should improve the accessibility and responsiveness of ethics consultation when needed. PMID:15009780

A Swarm Optimization approach for clinical knowledge mining.

PubMed

Christopher, J Jabez; Nehemiah, H Khanna; Kannan, A

2015-10-01

Rule-based classification is a typical data mining task that is being used in several medical diagnosis and decision support systems. The rules stored in the rule base have an impact on classification efficiency. Rule sets that are extracted with data mining tools and techniques are optimized using heuristic or meta-heuristic approaches in order to improve the quality of the rule base. In this work, a meta-heuristic approach called Wind-driven Swarm Optimization (WSO) is used. The uniqueness of this work lies in the biological inspiration that underlies the algorithm. WSO uses Jval, a new metric, to evaluate the efficiency of a rule-based classifier. Rules are extracted from decision trees. WSO is used to obtain different permutations and combinations of rules whereby the optimal ruleset that satisfies the requirement of the developer is used for predicting the test data. The performance of various extensions of decision trees, namely, RIPPER, PART, FURIA and Decision Tables are analyzed. The efficiency of WSO is also compared with the traditional Particle Swarm Optimization. Experiments were carried out with six benchmark medical datasets. The traditional C4.5 algorithm yields 62.89% accuracy with 43 rules for liver disorders dataset where as WSO yields 64.60% with 19 rules. For Heart disease dataset, C4.5 is 68.64% accurate with 98 rules where as WSO is 77.8% accurate with 34 rules. The normalized standard deviation for accuracy of PSO and WSO are 0.5921 and 0.5846 respectively. WSO provides accurate and concise rulesets. PSO yields results similar to that of WSO but the novelty of WSO lies in its biological motivation and it is customization for rule base optimization. The trade-off between the prediction accuracy and the size of the rule base is optimized during the design and development of rule-based clinical decision support system. The efficiency of a decision support system relies on the content of the rule base and classification accuracy. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

Dyadic OPTION: Measuring perceptions of shared decision-making in practice.

PubMed

Melbourne, Emma; Roberts, Stephen; Durand, Marie-Anne; Newcombe, Robert; Légaré, France; Elwyn, Glyn

2011-04-01

Current models of the medical consultation emphasize shared decision-making (SDM), whereby the expertise of both the doctor and the patient are recognised and seen to equally contribute to the consultation. The evidence regarding the desirability and effectiveness of the SDM approach is often conflicting. It is proposed that the conflicts are due to the nature of assessment, with current assessments from the perspective of an outside observer. To empirically assess perceived involvement in the medical consultation using the dyadic OPTION instrument. 36 simulated medical consultations were organised between general practitioners and standardized- patients, using the observer OPTION and the newly developed dyadic OPTION instruments. SDM behaviours observed in the consultations were seen to depend on both members of the doctor and patient dyad, rather than each in isolation. Thus a dyadic approach to measurement is supported. This current study highlights the necessity for a dyadic approach to assessment and introduces a novel research instrument: the dyadic OPTION instrument. Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.

Ethics Consultation in Pediatrics: Long-Term Experience from a Pediatric Oncology Center

PubMed Central

Johnson, Liza-Marie; Church, Christopher L.; Metzger, Monika; Baker, Justin N.

2015-01-01

There is little information about the content of ethics consultations (EC) in pediatrics. We sought to describe the reasons for consultation and ethical principles addressed during EC in pediatrics through retrospective review and directed content analysis of EC records (2000–2011) at St. Jude Children’s Research Hospital. Patient-based EC were highly complex and often involved evaluation of parental decision making, particularly consideration of the risks and benefits of a proposed medical intervention, and the physician’s fiduciary responsibility to the patient. Non-patient consultations provided guidance in the development of institutional policies that would broadly affect patients and families. This is one of the few existing reviews of the content of pediatric EC and indicates the distribution of ethical issues and reasons for moral distress are different than with adults. Pediatric EC often facilitates complex decision-making among multiple stakeholders and further prospective research is needed on the role of ethics consultation in pediatrics. PMID:25970382

Conformance Testing: Measurement Decision Rules

NASA Technical Reports Server (NTRS)

Mimbs, Scott M.

2010-01-01

The goal of a Quality Management System (QMS) as specified in ISO 9001 and AS9100 is to provide assurance to the customer that end products meet specifications. Measuring devices, often called measuring and test equipment (MTE), are used to provide the evidence of product conformity to specified requirements. Unfortunately, processes that employ MTE can become a weak link to the overall QMS if proper attention is not given to the measurement process design, capability, and implementation. Documented "decision rules" establish the requirements to ensure measurement processes provide the measurement data that supports the needs of the QMS. Measurement data are used to make the decisions that impact all areas of technology. Whether measurements support research, design, production, or maintenance, ensuring the data supports the decision is crucial. Measurement data quality can be critical to the resulting consequences of measurement-based decisions. Historically, most industries required simplistic, one-size-fits-all decision rules for measurements. One-size-fits-all rules in some cases are not rigorous enough to provide adequate measurement results, while in other cases are overly conservative and too costly to implement. Ideally, decision rules should be rigorous enough to match the criticality of the parameter being measured, while being flexible enough to be cost effective. The goal of a decision rule is to ensure that measurement processes provide data with a sufficient level of quality to support the decisions being made - no more, no less. This paper discusses the basic concepts of providing measurement-based evidence that end products meet specifications. Although relevant to all measurement-based conformance tests, the target audience is the MTE end-user, which is anyone using MTE other than calibration service providers. Topics include measurement fundamentals, the associated decision risks, verifying conformance to specifications, and basic measurement decisions rules.

Social contract theory and just decision making: lessons from genetic testing for the BRCA mutations.

PubMed

Williams-Jones, Bryn; Burgess, Michael M

2004-06-01

Decisions about funding health services are crucial to controlling costs in health care insurance plans, yet they encounter serious challenges from intellectual property protection--e.g., patents--of health care services. Using Myriad Genetics' commercial genetic susceptibility test for hereditary breast cancer (BRCA testing) in the context of the Canadian health insurance system as a case study, this paper applies concepts from social contract theory to help develop more just and rational approaches to health care decision making. Specifically, Daniel's and Sabin's "accountability for reasonableness" is compared to broader notions of public consultation, demonstrating that expert assessments in specific decisions must be transparent and accountable and supplemented by public consultation.

Automated rule-base creation via CLIPS-Induce

NASA Technical Reports Server (NTRS)

Murphy, Patrick M.

1994-01-01

Many CLIPS rule-bases contain one or more rule groups that perform classification. In this paper we describe CLIPS-Induce, an automated system for the creation of a CLIPS classification rule-base from a set of test cases. CLIPS-Induce consists of two components, a decision tree induction component and a CLIPS production extraction component. ID3, a popular decision tree induction algorithm, is used to induce a decision tree from the test cases. CLIPS production extraction is accomplished through a top-down traversal of the decision tree. Nodes of the tree are used to construct query rules, and branches of the tree are used to construct classification rules. The learned CLIPS productions may easily be incorporated into a large CLIPS system that perform tasks such as accessing a database or displaying information.

Requiem for the max rule?

PubMed

Ma, Wei Ji; Shen, Shan; Dziugaite, Gintare; van den Berg, Ronald

2015-11-01

In tasks such as visual search and change detection, a key question is how observers integrate noisy measurements from multiple locations to make a decision. Decision rules proposed to model this process have fallen into two categories: Bayes-optimal (ideal observer) rules and ad-hoc rules. Among the latter, the maximum-of-outputs (max) rule has been the most prominent. Reviewing recent work and performing new model comparisons across a range of paradigms, we find that in all cases except for one, the optimal rule describes human data as well as or better than every max rule either previously proposed or newly introduced here. This casts doubt on the utility of the max rule for understanding perceptual decision-making. Copyright © 2015 Elsevier Ltd. All rights reserved.

Option Grids to facilitate shared decision making for patients with Osteoarthritis of the knee: protocol for a single site, efficacy trial.

PubMed

Marrin, Katy; Wood, Fiona; Firth, Jill; Kinsey, Katharine; Edwards, Adrian; Brain, Kate E; Newcombe, Robert G; Nye, Alan; Pickles, Timothy; Hawthorne, Kamila; Elwyn, Glyn

2014-04-07

Despite policy interest, an ethical imperative, and evidence of the benefits of patient decision support tools, the adoption of shared decision making (SDM) in day-to-day clinical practice remains slow and is inhibited by barriers that include culture and attitudes; resources and time pressures. Patient decision support tools often require high levels of health and computer literacy. Option Grids are one-page evidence-based summaries of the available condition-specific treatment options, listing patients' frequently asked questions. They are designed to be sufficiently brief and accessible enough to support a better dialogue between patients and clinicians during routine consultations. This paper describes a study to assess whether an Option Grid for osteoarthritis of the knee (OA of the knee) facilitates SDM, and explores the use of Option Grids by patients disadvantaged by language or poor health literacy. This will be a stepped wedge exploratory trial involving 72 patients with OA of the knee referred from primary medical care to a specialist musculoskeletal service in Oldham. Six physiotherapists will sequentially join the trial and consult with six patients using usual care procedures. After a period of brief training in using the Option Grid, the same six physiotherapists will consult with six further patients using an Option Grid in the consultation. The primary outcome will be efficacy of the Option Grid in facilitating SDM as measured by observational scores using the OPTION scale. Comparisons will be made between patients who have received the Option Grid and those who received usual care. A Decision Quality Measure (DQM) will assess quality of decision making. The health literacy of patients will be measured using the REALM-R instrument. Consultations will be observed and audio-recorded. Interviews will be conducted with the physiotherapists, patients and any interpreters present to explore their views of using the Option Grid. Option Grids offer a potential solution to the barriers to implementing traditional decision aids into routine clinical practice. The study will assess whether Option Grids can facilitate SDM in day-to-day clinical practice and explore their use with patients disadvantaged by language or poor health literacy. Current Controlled Trials ISRCTN94871417.

Regulator Loss Functions and Hierarchical Modeling for Safety Decision Making.

PubMed

Hatfield, Laura A; Baugh, Christine M; Azzone, Vanessa; Normand, Sharon-Lise T

2017-07-01

Regulators must act to protect the public when evidence indicates safety problems with medical devices. This requires complex tradeoffs among risks and benefits, which conventional safety surveillance methods do not incorporate. To combine explicit regulator loss functions with statistical evidence on medical device safety signals to improve decision making. In the Hospital Cost and Utilization Project National Inpatient Sample, we select pediatric inpatient admissions and identify adverse medical device events (AMDEs). We fit hierarchical Bayesian models to the annual hospital-level AMDE rates, accounting for patient and hospital characteristics. These models produce expected AMDE rates (a safety target), against which we compare the observed rates in a test year to compute a safety signal. We specify a set of loss functions that quantify the costs and benefits of each action as a function of the safety signal. We integrate the loss functions over the posterior distribution of the safety signal to obtain the posterior (Bayes) risk; the preferred action has the smallest Bayes risk. Using simulation and an analysis of AMDE data, we compare our minimum-risk decisions to a conventional Z score approach for classifying safety signals. The 2 rules produced different actions for nearly half of hospitals (45%). In the simulation, decisions that minimize Bayes risk outperform Z score-based decisions, even when the loss functions or hierarchical models are misspecified. Our method is sensitive to the choice of loss functions; eliciting quantitative inputs to the loss functions from regulators is challenging. A decision-theoretic approach to acting on safety signals is potentially promising but requires careful specification of loss functions in consultation with subject matter experts.

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

PubMed Central

2014-01-01

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

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

PubMed

Shepherd, Andrew; Shorthouse, Oliver; Gask, Linda

2014-05-01

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

Adaptive decision rules for the acquisition of nature reserves.

PubMed

Turner, Will R; Wilcove, David S

2006-04-01

Although reserve-design algorithms have shown promise for increasing the efficiency of conservation planning, recent work casts doubt on the usefulness of some of these approaches in practice. Using three data sets that vary widely in size and complexity, we compared various decision rules for acquiring reserve networks over multiyear periods. We explored three factors that are often important in real-world conservation efforts: uncertain availability of sites for acquisition, degradation of sites, and overall budget constraints. We evaluated the relative strengths and weaknesses of existing optimal and heuristic decision rules and developed a new set of adaptive decision rules that combine the strengths of existing optimal and heuristic approaches. All three of the new adaptive rules performed better than the existing rules we tested under virtually all scenarios of site availability, site degradation, and budget constraints. Moreover, the adaptive rules required no additional data beyond what was readily available and were relatively easy to compute.

Adaptive comanagement of a marine protected area network in Fiji.

PubMed

Weeks, Rebecca; Jupiter, Stacy D

2013-12-01

Adaptive management of natural resources is an iterative process of decision making whereby management strategies are progressively changed or adjusted in response to new information. Despite an increasing focus on the need for adaptive conservation strategies, there remain few applied examples. We describe the 9-year process of adaptive comanagement of a marine protected area network in Kubulau District, Fiji. In 2011, a review of protected area boundaries and management rules was motivated by the need to enhance management effectiveness and the desire to improve resilience to climate change. Through a series of consultations, with the Wildlife Conservation Society providing scientific input to community decision making, the network of marine protected areas was reconfigured so as to maximize resilience and compliance. Factors identified as contributing to this outcome include well-defined resource-access rights; community respect for a flexible system of customary governance; long-term commitment and presence of comanagement partners; supportive policy environment for comanagement; synthesis of traditional management approaches with systematic monitoring; and district-wide coordination, which provided a broader spatial context for adaptive-management decision making. Co-Manejo Adaptativo de una Red de Áreas Marinas Protegidas en Fiyi. © 2013 The Authors. Conservation Biology published by Wiley Periodicals, Inc., on behalf of the Society for Conservation Biology.

Committees and Controversy: Consultants in the Construction of Education Policy

ERIC Educational Resources Information Center

Gabriel, Rachael; Paulus, Trena

2015-01-01

The increasingly common practice of engaging consulting firms to assist states with educational policy agendas requires an analysis of the role these consultants play in what is positioned as a democratic decision-making process. In this study, we examine the discourse of a state-level advisory committee formed to develop a new teacher evaluation…

Communication Consulting from Academe to the "Real World."

ERIC Educational Resources Information Center

Seiler, William J.; Dunning, David

Before adding consulting, training, or other work to the usual responsibilities of teaching, academicians must make a number of decisions. These include whether to work in or outside of academe, how much time they have available, whether they can meet the physical and mental demands of consulting, how to arrange for initial contacts, and how much…

Complementary treatment of psychotic and epileptic patients in malaysia.

PubMed

Razali, Salleh Mohd; Yassin, Azhar Mohd

2008-09-01

The objective of this article is to describe and compare the use of traditional/complementary medicine (T/CM) among psychotic (schizophrenia and schizophreniform disorder) and epileptic Malay patients in peninsular Malaysia. There were 60 patients in each group. T/CM consultation was uniformly spread across all levels of education and social status. We could not find a single over-riding factor that influenced the decision to seek T/CM treatment because the decision to seek such treatment was complex and the majority of decisions were made by others. Fifty-three patients (44.2%), consisting of 37 (61.7%) psychotic and 16 (26.7%) epileptic patients had consulted Malay traditional healers (bomoh) and/or homeopathic practitioners in addition to modern treatment; of these, only three had consulted bomoh and homeopathic practitioners at the same time. The use of T/CM was significantly higher in psychotic than in epileptic Malay patients.

Impact of clinical decision rules on clinical care of traumatic injuries to the foot and ankle, knee, cervical spine, and head.

PubMed

Perry, Jeffrey J; Stiell, Ian G

2006-12-01

Traumatic injuries to the ankle/foot, knee, cervical spine, and head are very commonly seen in emergency and accident departments around the world. There has been much interest in the development of clinical decision rules to help guide the investigations of these patients in a standardised and cost-effective manner. In this article we reviewed the impact of the Ottawa ankle rules, Ottawa knee rules, Canadian C-spine rule and the Canadian CT head rule. The studies conducted have confirmed that the use of well developed clinical decision rules results in less radiography, less time spent in the emergency department and does not decrease patient satisfaction or result in misdiagnosis. Emergency physicians around the world should adopt the use of clinical decision rules for ankle/foot, knee, cervical spine and minor head injuries. With relatively simple implementation strategies, care can be standardized and costs reduced while providing excellent clinical care.

20 CFR 220.50 - Consultative examinations at the Board's expense.

Code of Federal Regulations, 2010 CFR

2010-04-01

... examinations or tests. The decision to purchase a consultative examination will be made on an individual case... purchased for a claimant at the Board's request and expense. If the claimant's medical sources cannot...

Interpretable Decision Sets: A Joint Framework for Description and Prediction

PubMed Central

Lakkaraju, Himabindu; Bach, Stephen H.; Jure, Leskovec

2016-01-01

One of the most important obstacles to deploying predictive models is the fact that humans do not understand and trust them. Knowing which variables are important in a model’s prediction and how they are combined can be very powerful in helping people understand and trust automatic decision making systems. Here we propose interpretable decision sets, a framework for building predictive models that are highly accurate, yet also highly interpretable. Decision sets are sets of independent if-then rules. Because each rule can be applied independently, decision sets are simple, concise, and easily interpretable. We formalize decision set learning through an objective function that simultaneously optimizes accuracy and interpretability of the rules. In particular, our approach learns short, accurate, and non-overlapping rules that cover the whole feature space and pay attention to small but important classes. Moreover, we prove that our objective is a non-monotone submodular function, which we efficiently optimize to find a near-optimal set of rules. Experiments show that interpretable decision sets are as accurate at classification as state-of-the-art machine learning techniques. They are also three times smaller on average than rule-based models learned by other methods. Finally, results of a user study show that people are able to answer multiple-choice questions about the decision boundaries of interpretable decision sets and write descriptions of classes based on them faster and more accurately than with other rule-based models that were designed for interpretability. Overall, our framework provides a new approach to interpretable machine learning that balances accuracy, interpretability, and computational efficiency. PMID:27853627

Shared decision making or paternalism in nursing consultations? A qualitative study of primary care asthma nurses’ views on sharing decisions with patients regarding inhaler device selection

PubMed Central

Upton, Jane; Fletcher, Monica; Madoc‐Sutton, Hazel; Sheikh, Aziz; Caress, Ann‐Louise; Walker, Samantha

2011-01-01

Abstract Background  Although patients with asthma would like more involvement in the decision‐making process, and UK government policy concerning chronic conditions supports shared decision making, it is not widely used in practice. Objective  To investigate how nurses approach decision making in relation to inhaler choice and long‐term inhaler use within a routine asthma consultation and to better understand the barriers and facilitators to shared decision making in practice. Setting and participants  Semi‐structured interviews were conducted with post‐registration, qualified nurses who routinely undertook asthma consultations and were registered on a respiratory course. Interviews were recorded, transcribed and analysed using the Framework approach. Results  Twenty participants were interviewed. Despite holding positive views about shared decision making, limited shared decision making was reported. Opportunities for patients to share decisions were only offered in relation to inhaler device, which were based on the nurse’s pre‐selected recommendations. Giving patients this ‘choice’ was seen as key to improving adherence. Discussion  There is a discrepancy between nurses’ understanding of shared decision making and the depictions of shared decision making presented in the academic literature and NHS policy. In this study, shared decision making was used as a tool to support the nurses’ agenda, rather than as a natural expression of equality between the nurse and patient. Conclusion  There is a misalignment between the goals of practice nurses and the rhetoric regarding patient empowerment. Shared decision making may therefore only be embraced if it improves patient outcomes. This study indicates attitudinal shifts and improvements in knowledge of ‘shared decision‐making’ are needed if policy dictates are to be realised. PMID:21323822

76 FR 29675 - Assumption of Concurrent Federal Criminal Jurisdiction in Certain Areas of Indian Country

Federal Register 2010, 2011, 2012, 2013, 2014

2011-05-23

... the Attorney General, Department of Justice. ACTION: Proposed rule. SUMMARY: This rule proposes to... jurisdiction within the tribe's Indian country, and for the Attorney General to decide whether to consent to... request, and after consultation between the tribe and the Attorney General and consent to Federal...

Clinical Ethics Consultants are not “Ethics” Experts—But They do Have Expertise 1

PubMed Central

Rasmussen, Lisa M.

2016-01-01

The attempt to critique the profession of clinical ethics consultation by establishing the impossibility of ethics expertise has been a red herring. Decisions made in clinical ethics cases are almost never based purely on moral judgments. Instead, they are all-things-considered judgments that involve determining how to balance other values as well. A standard of justified decision-making in this context would enable us to identify experts who could achieve these standards more often than others, and thus provide a basis for expertise in clinical ethics consultation. This expertise relies in part on what Richard Zaner calls the “expert knowledge of ethical phenomena” (1988, 8). PMID:27302970

Risk communication in consultations about hormone therapy in the menopause: concordance in risk assessment and framing due to the context.

PubMed

Hoffmann, M; Hammar, M; Kjellgren, K I; Lindh-Astrand, L; Ahlner, J

2006-10-01

It is important for the physician and the patient to have a mutual understanding of the possible consequences of different treatment alternatives in order to achieve a partnership in decision-making. The aim of this study was to explore to which degree first-time consultations for discussion of climacteric discomfort achieved shared understanding of the risks and benefits associated with hormone therapy in the menopausal transition. Analysis of structure and content of transcribed consultations (n = 20), and follow-up interviews of the women (n = 19 pairs of consultations and interviews), from first-time visits for discussion of climacteric discomfort and/or HT with five physicians at three different outpatient clinics of gynecology in Sweden. Four distinctively different interpretations of risk, depending on whether or not benefits were discussed in the same context, emerged from the analysis. On average, five advantages (range 0-11) and two (0-3) disadvantages were mentioned during the consultations. In the interviews, the women expressed on average four advantages (0-7) and one disadvantage (0-3). There were major variations between advantages and disadvantages expressed in the consultation and the following interview. Even though the consultations scored high in patient involvement, the information in most consultations was not structured in a way that made it possible to achieve a shared or an informed decision-taking.

Malpractice liability for informal consultations.

PubMed

Olick, Robert S; Bergus, George R

2003-01-01

Informal ("curbside") consults are widely used by primary care physicians. These interactions occur in person, by telephone, or even by e-mail. Exposure to malpractice liability is a frequent concern of subspecialty physicians and influences their willingness to engage in this activity. To assess this risk, we reviewed reported judicial opinions involving informal consultation by physicians. A search of the existing medical literature, and of the Westlaw national database was undertaken to identify reported judicial opinions involving informal physician consults that address whether informal consultations create a legal relationship between consulting specialist physicians and patients that gives rise to a legal duty of care owed by the consulting specialist to the patient. Courts have consistently ruled that no physician-patient relationship exists between a consultant and the patient who is the focus of the informal consultation. In the absence of such a relationship, the courts have found no grounds for a claim of malpractice. Malpractice risks associated with informal consultation appear to be minimal, regardless of the method of communication. While "informal consultation" is not a term used by the courts, the courts have applied a consistent set of criteria that help define the legal parameters of this activity.

Decision Rules Used in Academic Program Closure: Where the Rubber Meets the Road.

ERIC Educational Resources Information Center

Eckel, Peter D.

This study examines, from an organizational perspective, decision rules guiding program discontinuance, testing the framework of decision rule rationality versus action rationality. A multi-site case study method was used; interviews were conducted with 11-16 individuals at each of four research I or II universities that had discontinued at least…

Pre-consultation educational group intervention to improve shared decision-making for postmastectomy breast reconstruction: a pilot randomized controlled trial.

PubMed

Causarano, Natalie; Platt, Jennica; Baxter, Nancy N; Bagher, Shaghayegh; Jones, Jennifer M; Metcalfe, Kelly A; Hofer, Stefan O P; O'Neill, Anne C; Cheng, Terry; Starenkyj, Elizabeth; Zhong, Toni

2015-05-01

Breast cancer survivors who make preference-sensitive decisions about postmastectomy breast reconstruction often have large gaps in knowledge and undergo procedures that are misaligned with their treatment goals. We evaluated the feasibility and effect of a pre-consultation educational group intervention on the decision-making process for breast reconstruction. We conducted a pilot randomized controlled trial (RCT) where participants were randomly assigned to the intervention with routine education or routine education alone. The outcomes evaluated were decisional conflict, decision self-efficacy, satisfaction with information, perceived involvement in care, and uptake of reconstruction following surgical consultation. Trial feasibility and acceptability were evaluated, and effect sizes were calculated to determine the primary outcome for the full-scale RCT. Of the 41 patients enrolled, recruitment rate was 72 %, treatment fidelity was 98 %, and retention rate was 95 %. The Cohen's d effect size in reduction of decisional conflict was moderate to high for the intervention group compared to routine education (0.69, 95 % CI = 0.02-1.42), while the effect sizes of increase in decision self-efficacy (0.05, 95 % CI = -0.60-0.71) and satisfaction with information (0.11, 95 % CI = -0.53-0.76) were small. A higher proportion of patients receiving routine education signed informed consent to undergo breast reconstruction (14/20 or 70 %) compared to the intervention group (8/21 or 38 %) P = 0.06. A pre-consultation educational group intervention improves patients' shared decision-making quality compared to routine preoperative patient education. A full-scale definitive RCT is warranted based on high feasibility outcomes, and the primary outcome for the main trial will be decisional conflict.

Logical-rule models of classification response times: a synthesis of mental-architecture, random-walk, and decision-bound approaches.

PubMed

Fific, Mario; Little, Daniel R; Nosofsky, Robert M

2010-04-01

We formalize and provide tests of a set of logical-rule models for predicting perceptual classification response times (RTs) and choice probabilities. The models are developed by synthesizing mental-architecture, random-walk, and decision-bound approaches. According to the models, people make independent decisions about the locations of stimuli along a set of component dimensions. Those independent decisions are then combined via logical rules to determine the overall categorization response. The time course of the independent decisions is modeled via random-walk processes operating along individual dimensions. Alternative mental architectures are used as mechanisms for combining the independent decisions to implement the logical rules. We derive fundamental qualitative contrasts for distinguishing among the predictions of the rule models and major alternative models of classification RT. We also use the models to predict detailed RT-distribution data associated with individual stimuli in tasks of speeded perceptual classification. PsycINFO Database Record (c) 2010 APA, all rights reserved.

Ban on commercial fishing in the estuarine waters of New South Wales, Australia: Community consultation and social impacts

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

Momtaz, Salim; Gladstone, William

2008-02-15

In its effort to resolve the conflict between commercial and recreational fishers the New South Wales (NSW) government (NSW Fisheries) banned commercial fishing in the estuarine waters. The NSW Fisheries conducted a number of studies and held meetings with the affected communities including commercial fishers prior to the implementation of the ban. To investigate how community consultation played a role in the decision-making process especially as perceived by the commercial fishers and to determine actual social impacts of the ban on commercial fishers, in-depth interviews were conducted with the commercial fishers. This research reveals that despite the NSW Fisheries' consultationsmore » with commercial fishers prior to the closure, the latter were confused about various vital aspects of the decision. It further reveals that, the commercial fishers faced a number of significant changes as a result of this decision. We argue that a better decision-making process and outcome would have been possible through a meaningful consultation with the commercial fishers and a social impact assessment.« less

Employee direct participation in organisational decisions and workplace safety.

PubMed

Widerszal-Bazyl, Maria; Warszewska-Makuch, Magdalena

2008-01-01

Managers from 192 companies filled out the Employee Direct Participation in Organisational Change questionnaire measuring employees' direct participation (DP) in organisational decisions. Four main forms of DP were identified: individual and group consultations, and individual and group delegation. Workplace safety was measured with the number of accidents, the number of employees working in hazardous conditions, accident absenteeism and sickness absence. Results showed that the 2 latter indicators were significantly related to some parameters of DP. Thus, companies that used face-to-face individual consultation had lower accident absenteeism than ones that did not. The same effect was true for group consultation with temporary groups, and individual and group delegation. Workplaces with high scores for scope for group consultation had lower accident absenteeism, and those with high scores for scope for group delegation had lower sickness absence. It was concluded that employee DP had a positive influence on workplace safety, even if involvement was not directly related to safety.

14 CFR 16.227 - Standard of proof.

Code of Federal Regulations, 2014 CFR

2014-01-01

... 14 Aeronautics and Space 1 2014-01-01 2014-01-01 false Standard of proof. 16.227 Section 16.227 Aeronautics and Space FEDERAL AVIATION ADMINISTRATION, DEPARTMENT OF TRANSPORTATION PROCEDURAL RULES RULES OF... hearing officer shall issue an initial decision or rule in a party's favor only if the decision or ruling...

Presenting Germany's drug pricing rule as a cost-per-QALY rule.

PubMed

Gandjour, Afschin

2012-06-01

In Germany, the Institute for Quality and Efficiency in Health Care (IQWiG) makes recommendations for ceiling prices of drugs based on an evaluation of the relationship between costs and effectiveness. To set ceiling prices, IQWiG uses the following decision rule: the incremental cost-effectiveness ratio of a new drug compared with the next effective intervention should not be higher than that of the next effective intervention compared to its comparator. The purpose of this paper is to show that IQWiG's decision rule can be presented as a cost-per-QALY rule by using equity-weighted QALYs. This transformation shows where both rules share commonalities. Furthermore, it makes the underlying ethical implications of IQWiG's decision rule transparent and open to debate.

Emergency physicians' attitudes toward and use of clinical decision rules for radiography.

PubMed

Graham, I D; Stiell, I G; Laupacis, A; O'Connor, A M; Wells, G A

1998-02-01

1) To assess Canadian emergency physicians' (EPs') use of and attitudes toward 2 radiographic clinical decision rules that have recently been developed and to identify physician characteristics associated with decision rule use; 2) to determine the use of CT head and cervical spine radiography by EPs and their beliefs about the appropriateness of expert recommendations supporting the routine use of these radiographic procedures; and 3) to determine the potential acceptance of clinical decision rules for CT scan in patients with minor head injury and cervical spine radiography in trauma patients. A cross-sectional anonymous mail survey of a random sample of 300 members of the Canadian Association of Emergency Physicians using Dillman's Total Design Method for mail surveys. Of 288 eligible physicians, 232 (81%) responded. More than 95% of the respondents stated they currently used the Ottawa Ankle Rules and were willing to consider using the newly developed Ottawa Knee Rule. Physician characteristics related to frequent use of the Ottawa Ankle Rules were younger age, fewer years since graduating from medical school, part time or resident employment status, working in a hospital without a CT scanner, and believing that decision rules are not oversimplified cookbook medicine or too rigid to apply. Eighty-five percent did not agree that all patients with minor head injuries should receive a CT head scan and only 3.5% stated they always refer such patients for CT scan. Similarly, 78.5% of the respondents did not agree that all trauma patients should receive cervical spine radiography and only 13.2% said they always refer such patients for cervical spine radiography. Ninety-seven and 98% stated they would be willing to consider using well-validated decision rules for CT scan of the head and cervical spine radiography, respectively. Fifty-two percent and 67% of the respondents required the proposed CT and C-spine to be 100% sensitive for identifying serious injuries, respectively. Canadian EPs are generally supportive of clinical decision rules and, in particular, have very positive attitudes toward the Ottawa Ankle and Knee Rules. Furthermore, EPs disagree with recommendations for routine use of CT head and cervical spine radiography and strongly support the development of well-validated decision rules for the use of CT head and cervical spine radiography. Most EPs expected the latter rules to be 100% sensitive for acute clinically significant lesions.

Portfolio theory and the alternative decision rule of cost-effectiveness analysis: theoretical and practical considerations.

PubMed

Sendi, Pedram; Al, Maiwenn J; Gafni, Amiram; Birch, Stephen

2004-05-01

Bridges and Terris (Soc. Sci. Med. (2004)) critique our paper on the alternative decision rule of economic evaluation in the presence of uncertainty and constrained resources within the context of a portfolio of health care programs (Sendi et al. Soc. Sci. Med. 57 (2003) 2207). They argue that by not adopting a formal portfolio theory approach we overlook the optimal solution. We show that these arguments stem from a fundamental misunderstanding of the alternative decision rule of economic evaluation. In particular, the portfolio theory approach advocated by Bridges and Terris is based on the same theoretical assumptions that the alternative decision rule set out to relax. Moreover, Bridges and Terris acknowledge that the proposed portfolio theory approach may not identify the optimal solution to resource allocation problems. Hence, it provides neither theoretical nor practical improvements to the proposed alternative decision rule.

Hybrid forum or network? The social and political construction of an international 'technical consultation': male circumcision and HIV prevention.

PubMed

Giami, Alain; Perrey, Christophe; Mendonça, André Luiz de Oliveira; de Camargo, Kenneth Rochel

2015-01-01

The technical consultation in Montreux, organised by World Health Organization and UNAIDS in 2007, recommended male circumcision as a method for preventing HIV transmission. This consultation came out of a long process of releasing reports and holding international and regional conferences, a process steered by an informal network. This network's relations with other parties is analysed along with its way of working and the exchanges during the technical consultation that led up to the formal adoption of a recommendation. Conducted in relation to the concepts of a 'hybrid forum' and 'network', this article shows that the decision was based on the formation and consolidation of a network of persons. They were active in all phases of this process, ranging from studies of the recommendation's efficacy, feasibility and acceptability to its adoption and implementation. In this sense, this consultation cannot be described as the constitution of a 'hybrid forum', which is characterised by its openness to a debate as well as a plurality of issues formulated by the actors and of resources used by them. On the contrary, little room was allowed for contradictory discussions, as if the decision had already been made before the Montreux consultation.

Attracting Child Psychiatrists to a Televideo Consultation Service: The TeleLink Experience.

PubMed

Volpe, Tiziana; Boydell, Katherine M; Pignatiello, Antonio

2013-01-01

Objective. Identify aspects of psychiatry work that are rewarding, as well as those that are challenging, from the perspective of psychiatrists and residents participating in televideo consultation services. Method. A web-based survey was distributed to psychiatrists within the Division of Child Psychiatry at the University of Toronto. Also, semistructured interviews were conducted with six child psychiatrists providing services to a telepsychiatry program. Finally, a focus group interview was held with four psychiatry residents. Results. Child psychiatrists are very comfortable conducting assessments via televideo. Factors identified as being important in the decision to participate in telepsychiatry include assisting underserved communities, supportive administrative staff, enhanced rural provider capacity, financial incentives, and convenience. The study's qualitative phase identified four themes in the decision to participate in telepsychiatry: (1) organizational, (2) shared values, (3) innovation, and (4) the consultation model. Conclusion. The success of televideo consultation programs in attracting child psychiatrists to provide consultation services to underresourced communities makes an important contribution to psychiatric workforce shortages. Understanding what aspects of telepsychiatry are most appreciated by consulting psychiatrists and residents offers useful strategies to telepsychiatry administrators and medical school educators seeking to attract, train, and retain psychiatry practitioners.

Attracting Child Psychiatrists to a Televideo Consultation Service: The TeleLink Experience

PubMed Central

Boydell, Katherine M.; Pignatiello, Antonio

2013-01-01

Objective. Identify aspects of psychiatry work that are rewarding, as well as those that are challenging, from the perspective of psychiatrists and residents participating in televideo consultation services. Method. A web-based survey was distributed to psychiatrists within the Division of Child Psychiatry at the University of Toronto. Also, semistructured interviews were conducted with six child psychiatrists providing services to a telepsychiatry program. Finally, a focus group interview was held with four psychiatry residents. Results. Child psychiatrists are very comfortable conducting assessments via televideo. Factors identified as being important in the decision to participate in telepsychiatry include assisting underserved communities, supportive administrative staff, enhanced rural provider capacity, financial incentives, and convenience. The study's qualitative phase identified four themes in the decision to participate in telepsychiatry: (1) organizational, (2) shared values, (3) innovation, and (4) the consultation model. Conclusion. The success of televideo consultation programs in attracting child psychiatrists to provide consultation services to underresourced communities makes an important contribution to psychiatric workforce shortages. Understanding what aspects of telepsychiatry are most appreciated by consulting psychiatrists and residents offers useful strategies to telepsychiatry administrators and medical school educators seeking to attract, train, and retain psychiatry practitioners. PMID:23864854

Why do dyspeptic patients over the age of 50 consult their general practitioner? A qualitative investigation of health beliefs relating to dyspepsia.

PubMed Central

Delaney, B C

1998-01-01

BACKGROUND: The prognosis of late-diagnosed gastric cancer is poor, yet less than half of dyspeptic patients consult their general practitioner (GP). AIM: To construct an explanatory model of the decision to consult with dyspepsia in older patients. METHOD: A total of 75 patients over the age of 50 years who had consulted with dyspepsia at one of two inner city general practices were invited to an in-depth interview. The interviews were taped, transcribed, and analysed using the computer software NUD.IST, according to the principles of grounded theory. RESULTS: Altogether, 31 interviews were conducted. The perceived threat of cancer and the need for reassurance were key influences on the decision to consult. Cues such as a change in symptoms were important in prompting a re-evaluation of the likely cause. Personal vulnerability to serious illness was often mentioned in the context of family or friends' experience, but tempered by an individual's life expectations. CONCLUSION: Most patients who had delayed consultation put their symptoms down to 'old age' or 'spicy food'. However, a significant minority were fatalistic, suspecting the worst but fearing medical interventions. PMID:10024706

SUPPORT NEEDS AND ACCEPTABILITY OF PSYCHOLOGICAL CONSULTATION: ATTITUDES OF 108 WOMEN WHO HAD UNDERGONE OR WERE CONSIDERING PROPHYLACTIC MASTECTOMY

PubMed Central

Patenaude, Andrea F; Orozco, Sara; Li, Xiaochun; Kaelin, Carolyn M; Gadd, Michelle; Matory, Yvedt; Mayzel, Kathleen; Roche, Constance A; Smith, Barbara L; Farkas, Walden; Garber, Judy E

2014-01-01

Summary Prophylactic mastectomy (PM) offers 90% or greater reduction in risk of breast cancer to women at increased hereditary risk. Nonetheless, acceptance in North America has been low (0–36%). Most women report reduced cancer worry post-operatively, but up to 25–50% of women electing surgery also report psychological distress and/or difficulty adapting following PM. Psychological consultation to aid decision-making and improve post-surgical coping isn’t routinely offered. This retrospective, cross-sectional study explored, quantitatively and qualitatively, interest in and acceptability of psychological consultation for issues related to PM among 108 women who had undergone or were considering surgery. Of the 71 women who had undergone PM, more than half felt pre-surgical psychological consultation was advisable and nearly 2/3 felt post-surgical psychological consultation would be helpful. All 37 women (100%) currently considering PM believed psychological consultation would aid decision-making and preparation for surgery. Narratives from the interviews illustrate the nature and intensity of the need for psychological support and describe preferences for the role of the psychologist. Suggestions are offered for the integration of psychological services for women deciding about or adapting to PM. PMID:18636423

Awareness and use of the Ottawa ankle and knee rules in 5 countries: can publication alone be enough to change practice?

PubMed

Graham, I D; Stiell, I G; Laupacis, A; McAuley, L; Howell, M; Clancy, M; Durieux, P; Simon, N; Emparanza, J I; Aginaga, J R; O'connor, A; Wells, G

2001-03-01

We evaluate the international diffusion of the Ottawa Ankle and Knee Rules and determine emergency physicians' attitudes toward clinical decision rules in general. We conducted a cross-sectional, self-administered mail survey of random samples of 500 members each of the American College of Emergency Physicians, Canadian Association of Emergency Physicians, British Association for Accident and Emergency Medicine, Spanish Society for Emergency Medicine, and all members (n=1,350) of the French Speaking Society of Emergency Physicians, France. Main outcome measures were awareness of the Ottawa Ankle and Knee Rules, reported use of these rules, and attitudes toward clinical decision rules in general. A total of 1,769 (57%) emergency physicians responded, with country-specific response rates between 49% (United States and France) and 79% (Canada). More than 69% of physicians in all countries, except Spain, were aware of the Ottawa Ankle Rules. Use of the Ottawa Ankle Rules differed by country with more than 70% of all responding Canadian and United Kingdom physicians reporting frequent use of the rules compared with fewer than one third of US, French, and Spanish physicians. The Ottawa Knee Rule was less well known and less used by physicians in all countries. Most physicians in all countries viewed decision rules as intended to improve the quality of health care (>78%), a convenient source of advice (>67%), and good educational tools (>61%). Of all physicians, those from the United States held the least positive attitudes toward decision rules. This constitutes the largest international survey of emergency physicians' attitudes toward and use of clinical decision rules. Striking differences were apparent among countries with regard to knowledge and use of decision rules. Despite similar awareness in the United States, Canada, and the United Kingdom, US physicians appeared much less likely to use the Ottawa Ankle Rules. Future research should investigate factors leading to differences in rates of diffusion among countries and address strategies to enhance dissemination and implementation of such rules in the emergency department.

Effect of patient decision aid was influenced by presurgical evaluation among patients with osteoarthritis of the knee.

PubMed

Boland, Laura; Taljaard, Monica; Dervin, Geoffrey; Trenaman, Logan; Tugwell, Peter; Pomey, Marie-Pascale; Stacey, Dawn

2017-12-01

Decision aids help patients make total joint arthroplasty decisions, but presurgical evaluation might influence the effects of a decision aid. We compared the effects of a decision aid among patients considering total knee arthroplasty at 2 surgical screening clinics with different evaluation processes. We performed a subgroup analysis of a randomized controlled trial. Patients were recruited from 2 surgical screening clinics: an academic clinic providing 20-minute physician consultations and a community clinic providing 45-minute physiotherapist/nurse consultations with education. We compared the effects of decision quality, decisional conflict and surgery rate using Cochran-Mantel-Haenszel χ 2 tests and the Breslow-Day test. We evaluated 242 patients: 123 from the academic clinic (61 who used the decision aid and 62 controls) and 119 from the community clinic (59 who used the decision aid and 60 controls). Results suggested a between-site difference in the effect of the decision aid on the patients' decision quality ( p = 0.09): at the academic site, patients who used the decision were more likely to make better-quality decisions than controls (54% v. 35%, p = 0.044), but not at the community site (47% v. 51%, p = 0.71). Fewer patients who used decision aids at the academic site than at the community site experienced decisional conflict ( p = 0.007) (33% v. 52%, p = 0.05 at the academic site and 40% v. 24%, p = 0.08 at the community site). The effect of the decision aid on surgery rates did not differ between sites ( p = 0.65). The decision aid had a greater effect at the academic site than at the community site, which provided longer consultations with more verbal education. Hence, decision aids might be of greater value when more extensive total knee arthroplasty presurgical assessment and counselling are either impractical or unavailable.

Effect of patient decision aid was influenced by presurgical evaluation among patients with osteoarthritis of the knee.

PubMed

Boland, Laura; Taljaard, Monica; Dervin, Geoffrey; Trenaman, Logan; Tugwell, Peter; Pomey, Marie-Pascale; Stacey, Dawn

2018-02-01

Decision aids help patients make total joint arthroplasty decisions, but presurgical evaluation might influence the effects of a decision aid. We compared the effects of a decision aid among patients considering total knee arthroplasty at 2 surgical screening clinics with different evaluation processes. We performed a subgroup analysis of a randomized controlled trial. Patients were recruited from 2 surgical screening clinics: an academic clinic providing 20-minute physician consultations and a community clinic providing 45-minute physiotherapist/nurse consultations with education. We compared the effects of decision quality, decisional conflict and surgery rate using Cochran-Mantel-Haenszel χ 2 tests and the Breslow-Day test. We evaluated 242 patients: 123 from the academic clinic (61 who used the decision aid and 62 controls) and 119 from the community clinic (59 who used the decision aid and 60 controls). Results suggested a between-site difference in the effect of the decision aid on the patients' decision quality ( p = 0.09): at the academic site, patients who used the decision aid were more likely to make better-quality decisions than controls (54% v. 35%, p = 0.044), but not at the community site (47% v. 51%, p = 0.71). Fewer patients who used decision aids at the academic site than at the community site experienced decisional conflict ( p = 0.007) (33% v. 52%, p = 0.05 at the academic site and 40% v. 24%, p = 0.08 at the community site). The effect of the decision aid on surgery rates did not differ between sites ( p = 0.65). The decision aid had a greater effect at the academic site than at the community site, which provided longer consultations with more verbal education. Hence, decision aids might be of greater value when more extensive total knee arthroplasty presurgical assessment and counselling are either impractical or unavailable.

Estimating Classification Accuracy for Complex Decision Rules Based on Multiple Scores

ERIC Educational Resources Information Center

Douglas, Karen M.; Mislevy, Robert J.

2010-01-01

Important decisions about students are made by combining multiple measures using complex decision rules. Although methods for characterizing the accuracy of decisions based on a single measure have been suggested by numerous researchers, such methods are not useful for estimating the accuracy of decisions based on multiple measures. This study…

Connecting clinical and actuarial prediction with rule-based methods.

PubMed

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

2015-06-01

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

IRIS Toxicological Review of Tert-Butyl Alcohol (Tert-Butanol) ...

EPA Pesticide Factsheets

On April 29, 2016, the Toxicological Review of tert-Butyl Alcohol (tert-Butanol) (Public Comment Draft) was released for public comment. The draft Toxicological Review and charge were reviewed internally by EPA and by other federal agencies and the Executive Office of the President during Step 3 (Interagency Science Consultation) before public release. As part of the IRIS process, all written interagency comments on IRIS assessments will be made publicly available. Accordingly, interagency comments with EPA's response and the interagency science consultation drafts of the IRIS Toxicological Review of tert-Butanol and charge to external peer reviewers are posted on this site. EPA is undertaking a new health assessment for t-butyl alcohol (tert-butanol) for the Integrated Risk Information System (IRIS). The outcome of this project will be a Toxicological Review and IRIS and IRIS Summary of TBA that will be entered on the IRIS database. IRIS is an EPA database containing Agency scientific positions on potential adverse human health effects that may result from chronic (or lifetime) exposure to chemicals in the environment. IRIS contains chemical-specific summaries of qualitative and quantitative health information to evaluate potential public health risks associated with environmental contaminants. The IRIS database is relied on for the development of risk assessments, site-specific environmental decisions, and rule making.

Knowledge Based Consultation for Finite Element Structural Analysis.

DTIC Science & Technology

1980-05-01

Intelligence Finite Element Program Tutorial 20 ABSTRACT (Continue. on rees side If necessary and ide.n’ty b,’ bit,, k nionh.) In recent years, techniques of...involved in Artificial Intelligence at Stanford University developed the program MYCIN F2], for clinical consultation of diseases that require...and Rules The basic backward chaining logic, characteristic to Artificial Intelligence . approaching 1he problem of knowledge representation was

32 CFR 855.2 - Responsibilities.

Code of Federal Regulations, 2010 CFR

2010-07-01

... authority. All decisions are subject to the environmental impact analysis process as directed by the... instructions. The decision process includes consultation with other affected functional area managers when...

Narrative dynamics in social groups: A discrete choice model

NASA Astrophysics Data System (ADS)

Antoci, A.; Bellanca, N.; Galdi, G.; Sodini, M.

2018-05-01

Individuals follow different rules for action: they react swiftly, grasping the short-term advantages in sight, or they waste cognitive resources to complete otherwise easy tasks, but they are able to plan ahead future complex decisions. Scholars from different disciplines studied the conditions under which either decision rule may enhance the fitness of its adopters, with a focus on the environmental features. However, we here propose that a crucial feature of the evolution of populations and their decision rules is rather inter-group interactions. Indeed, we study what happens when two groups support different decision rules, encapsulated in narratives, and their populations interact with each other. In particular, we assume that the payoff of each rule depends on the share of both social groups which adopt such rules. We then describe the most salient dynamics scenarios and identify the conditions which lead to chaotic dynamics and multistability regimes.

Do Patient Characteristics Decide if Young Adult Cancer Patients Undergo Fertility Preservation?

PubMed

Flink, Dina M; Sheeder, Jeanelle; Kondapalli, Laxmi A

2017-06-01

The Fertility Attitudes and Cancer Treatment Study (FACTS) is a two-phase research initiative aimed to understand factors involved with decision making for future fertility. The FACTS will improve services and utilization of fertility preservation (FP) before cancer treatment. Phase-I examined patient characteristics as associated with FP decision. A retrospective cohort study of 108 reproductive-aged (18-45 years) males and females who received a fertility consultation before cancer treatment from January 1, 2012 to April 30, 2014 was conducted. Chi-square, student's t-test, and logistic regression were conducted to examine associations with FP decision. The utilization rate of FP following fertility consultation was 49%. Gender was the most significant factor contributing to FP decision; 74% of those who choose FP were male (odds ratio = 12.5; 95% confidence interval 5.1-31.4). Those who opted for FP were more likely to be Caucasian (p = 0.042), have a solid tumor (p = 0.03), and have a shorter time from diagnosis to fertility consultation (29.5 vs. 58.8 days; p = 0.017). Age, relationship, tumor location, treatment plan, and parity were not significant predictors of FP. Current perceptions about patient demographics do not predict FP utilization by young adult cancer patients. Providing patients an informed fertility consultation has demonstrated an increase in FP utilization to nearly one-half of patients. Despite gender being a significant factor in choosing FP, the study did not provide reasons as to why. The phase-II study will explore patients' reasons for FP decision in a qualitative design to understand these differences.

Assessments of the extent to which health-care providers involve patients in decision making: a systematic review of studies using the OPTION instrument.

PubMed

Couët, Nicolas; Desroches, Sophie; Robitaille, Hubert; Vaillancourt, Hugues; Leblanc, Annie; Turcotte, Stéphane; Elwyn, Glyn; Légaré, France

2015-08-01

We have no clear overview of the extent to which health-care providers involve patients in the decision-making process during consultations. The Observing Patient Involvement in Decision Making instrument (OPTION) was designed to assess this. To systematically review studies that used the OPTION instrument to observe the extent to which health-care providers involve patients in decision making across a range of clinical contexts, including different health professions and lengths of consultation. We conducted online literature searches in multiple databases (2001-12) and gathered further data through networking. (i) OPTION scores as reported outcomes and (ii) health-care providers and patients as study participants. For analysis, we only included studies using the revised scale. Extracted data included: (i) study and participant characteristics and (ii) OPTION outcomes (scores, statistical associations and reported psychometric results). We also assessed the quality of OPTION outcomes reporting. We found 33 eligible studies, 29 of which used the revised scale. Overall, we found low levels of patient-involving behaviours: in cases where no intervention was used to implement shared decision making (SDM), the mean OPTION score was 23 ± 14 (0-100 scale). When assessed, the variables most consistently associated with higher OPTION scores were interventions to implement SDM (n = 8/9) and duration of consultations (n = 8/15). Whatever the clinical context, few health-care providers consistently attempt to facilitate patient involvement, and even fewer adjust care to patient preferences. However, both SDM interventions and longer consultations could improve this. © 2013 John Wiley & Sons Ltd.

Achieving involvement: process outcomes from a cluster randomized trial of shared decision making skill development and use of risk communication aids in general practice.

PubMed

Elwyn, G; Edwards, A; Hood, K; Robling, M; Atwell, C; Russell, I; Wensing, M; Grol, R

2004-08-01

A consulting method known as 'shared decision making' (SDM) has been described and operationalized in terms of several 'competences'. One of these competences concerns the discussion of the risks and benefits of treatment or care options-'risk communication'. Few data exist on clinicians' ability to acquire skills and implement the competences of SDM or risk communication in consultations with patients. The aims of this study were to evaluate the effects of skill development workshops for SDM and the use of risk communication aids on the process of consultations. A cluster randomized trial with crossover was carried out with the participation of 20 recently qualified GPs in urban and rural general practices in Gwent, South Wales. A total of 747 patients with known atrial fibrillation, prostatism, menorrhagia or menopausal symptoms were invited to a consultation to review their condition or treatments. Half the consultations were randomly selected for audio-taping, of which 352 patients attended and were audio-taped successfully. After baseline, participating doctors were randomized to receive training in (i) SDM skills or (ii) the use of simple risk communication aids, using simulated patients. The alternative training was then provided for the final study phase. Patients were allocated randomly to a consultation during baseline or intervention 1 (SDM or risk communication aids) or intervention 2 phases. A randomly selected half of the consultations were audio-taped from each phase. Raters (independent, trained and blinded to study phase) assessed the audio-tapes using a validated scale to assess levels of patient involvement (OPTION: observing patient involvement), and to analyse the nature of risk information discussed. Clinicians completed questionnaires after each consultation, assessing perceived clinician-patient agreement and level of patient involvement in decisions. Multilevel modelling was carried out with the OPTION score as the dependent variable, and rater, consultation and clinician levels of data, standardized by rater within clinician. Following each of the interventions, the clinicians significantly increased their involvement of patients in decision making (OPTION score increased by 10.6 following risk communication training [95% confidence interval (CI) 7.9 -13.3; P < 0.001] and by 12.9 after SDM skill development (95% CI 10 -15.8, P < 0.001), a moderate effect size. The level of involvement achieved by the risk communication aids was significantly increased by the subsequent introduction of the skill development workshops (7.7 increase in OPTION score, 95% CI 3.4-12; P < 0.001). The alternative sequence (skills followed by risk communication aids) did not achieve this effect. The use of most risk information formats increased after the provision of specific risk communication aids (P < 0.001). Clinicians using the risk communication tools perceived significantly higher patient and clinician agreement on treatment (P < 0.001), patient satisfaction with information (P < 0.01), clinician satisfaction with decision (P < 0.01) and general overall satisfaction with the consultation (P < 0.001) than those who were exposed to SDM skill development workshops. These clinicians were able to acquire the skills to implement SDM competences and to use risk communication aids. Each intervention provided independent effects. Further progress towards greater patient involvement in health care decision making is possible, and skill development in this area should be incorporated into postgraduate professional development programmes.

The US Court of Appeals for the D.C. Circuit Ruling to Stay the CSAPR

EPA Pesticide Factsheets

The United States Court of Appeals for the D.C. Circuit issued its ruling to stay the CSAPR pending judicial review. The court's decision is not a decision on the merits of the rule. EPA is ensuring the transition back to the Clean Air Interstate Rule.

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/.

Is expected utility theory normative for medical decision making?

PubMed

Cohen, B J

1996-01-01

Expected utility theory is felt by its proponents to be a normative theory of decision making under uncertainty. The theory starts with some simple axioms that are held to be rules that any rational person would follow. It can be shown that if one adheres to these axioms, a numerical quantity, generally referred to as utility, can be assigned to each possible outcome, with the preferred course of action being that which has the highest expected utility. One of these axioms, the independence principle, is controversial, and is frequently violated in experimental situations. Proponents of the theory hold that these violations are irrational. The independence principle is simply an axiom dictating consistency among preferences, in that it dictates that a rational agent should hold a specified preference given another stated preference. When applied to preferences between lotteries, the independence principle can be demonstrated to be a rule that is followed only when preferences are formed in a particular way. The logic of expected utility theory is that this demonstration proves that preferences should be formed in this way. An alternative interpretation is that this demonstrates that the independence principle is not a valid general rule of consistency, but in particular, is a rule that must be followed if one is to consistently apply the decision rule "choose the lottery that has the highest expected utility." This decision rule must be justified on its own terms as a valid rule of rationality by demonstration that violation would lead to decisions that conflict with the decision maker's goals. This rule does not appear to be suitable for medical decisions because often these are one-time decisions in which expectation, a long-run property of a random variable, would not seem to be applicable. This is particularly true for those decisions involving a non-trivial risk of death.

General practice consultations and use of prescription drugs after changes to school absence policy.

PubMed

Bakken, Inger Johanne; Wensaas, Knut-Arne; Furu, Kari; Grøneng, Gry Marysol; Stoltenberg, Camilla; Øverland, Simon; Håberg, Siri Eldevik

2017-09-05

New rules for absence with stricter requirements for documentation were introduced in upper secondary schools in the autumn of 2016. We investigated the use of general practice services and dispensing of prescription drugs among 16 – 18-year-olds in the autumn of 2016 and compared this with equivalent figures for the period 2013 – 15. We retrieved information on consultations in general practice (GP) and dispensing of prescription drugs to 15 – 18-year-olds in the period 2013 – 16 from the Directorate of Health’s system for control and payment of health reimbursements (KUHR) and the Norwegian Prescription Database respectively. The number of consultations and dispensing of drugs were compared to previous years using Poisson regression (reference year 2015). The incidence rate ratio (IRR) was used as an outcome measure. The number of GP consultations for 16 – 18-year-olds was 30 % higher in the autumn of 2016 than in the autumn of 2015 (IRR 1.30, 95 % confidence interval (CI) 1.29 – 1.31). In the same period, the dispensing of drugs to this age group increased by 8 % (IRR 1.08, 95 % CI 1.08 – 1.09). Among the diagnosis groups, respiratory tract infections had the largest increase (IRR 2.21, 95 % CI 2.17 – 2.25). The largest increase in drug dispensing was found for remedies for coughs and colds (IRR 1.73, 95 % CI 1.65 – 1.80). The increase in consultations in general practice and dispensing of drugs to 16 – 18-year-olds coincided in time with the introduction of new rules for absence from school. We hold it to be highly likely that the changes were caused by the stricter rules for documentation of absence from school.

20 CFR 668.130 - What obligation do we have to consult with the INA grantee community in developing rules...

Code of Federal Regulations, 2010 CFR

2010-04-01

... grantee community as a full partner in developing policies for the INA programs. We will actively seek and... the INA grantee community in developing rules, regulations, and standards of accountability for INA programs? 668.130 Section 668.130 Employees' Benefits EMPLOYMENT AND TRAINING ADMINISTRATION, DEPARTMENT OF...

20 CFR 668.130 - What obligation do we have to consult with the INA grantee community in developing rules...

Code of Federal Regulations, 2011 CFR

2011-04-01

... grantee community as a full partner in developing policies for the INA programs. We will actively seek and... the INA grantee community in developing rules, regulations, and standards of accountability for INA programs? 668.130 Section 668.130 Employees' Benefits EMPLOYMENT AND TRAINING ADMINISTRATION, DEPARTMENT OF...

76 FR 61416 - Self-Regulatory Organizations; The Nasdaq Stock Market LLC; Notice of Filing of Proposed Rule...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-10-04

... Methodology for Determining When to Halt Trading Due to Extraordinary Market Volatility September 28, 2011... determining when to halt trading in all stocks due to extraordinary market volatility. The proposal is made in... market volatility. The Exchange is proposing this rule change in consultation with other equity, options...

76 FR 61435 - Self-Regulatory Organizations; NASDAQ OMX BX, Inc.; Notice of Filing of Proposed Rule Change To...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-10-04

... Determining When to Halt Trading Due to Extraordinary Market Volatility September 28, 2011. Pursuant to... trading in all stocks due to extraordinary market volatility. The proposal is made in conjunction with all... to extraordinary market volatility. The Exchange is proposing this rule change in consultation with...

When a physician and a clinical ethicist collaborate for better patient care.

PubMed

Arawi, Thalia; Charafeddine, Lama

2018-06-01

Bioethics is a relatively new addition to bedside medical care in Arab world which is characterized by a special culture that often makes blind adaptation of western ethics codes and principles; a challenge that has to be faced. To date, the American University of Beirut Medical Center is the only hospital that offers bedside ethics consultations in the Arab Region aiming towards better patient-centered care. This article tackles the role of the bedside clinical ethics consultant as an active member of the medical team and the impact of such consultations on decision-making and patient-centered care. Using the case of a child with multiple medical problems and a futile medical condition, we describe how the collaboration of the medical team and the clinical ethics consultant took a comprehensive approach to accompany and lead the parents and the medical team in their decision-making process and how the consultations allowed several salient issues to be addressed. This approach proved to be effective in the Arab cultural setting and indeed did lead to better patientcentered care. © 2018 John Wiley & Sons Ltd.

Prophylactic Mastectomy: Impact and Intervention

DTIC Science & Technology

2001-10-01

self - esteem , marital and family relationships, etc. A psychological consultation offered to women making this irreversible decision would likely improve decision-making and subsequent coping. Design of this consultation is best informed by data about physical and emotional effects of surgery from women who have had this procedure. In Year 2 we conducted taped, telephone interviews with women with cancer in one breast who had both breasts removed (49 enrolled), women who had both breasts removed prophylactically (15 enrolled), and women considering PM (16 enrolled). We aim

Patient decision-making preference and physician decision-making style for contraceptive method choice in an Asian culture: does concordance matter?

PubMed

Alden, Dana Latham; Merz, Miwa Yamazaki; Thi, Le Minh

2010-12-01

This study investigates preferences for patient-physician decision-making in an emerging economy with an Asian culture. A survey of 445 randomly sampled women, aged 20-40 in Hanoi, Vietnam, revealed that pre-consultation attitudes were most positive toward a "shared" decision-making approach with the physician for contraceptive method choice. However, following random assignment to one of three vignettes (passive, shared or autonomous) featuring a young Vietnamese woman reaching a contraceptive method decision with her physician, preference was highest for the "autonomous" approach. Furthermore, discordance between pre-consultation preference for decision-making style and the physician's decision-making style negatively impacted evaluations under some but not all circumstances. This study demonstrates that, despite living in a hierarchic Asian culture, active participation in contraceptive method choice is desired by many urban Vietnamese women. However, there is variation on this dimension and adjusting the physician's style to be concordant with patient preference appears important to maximizing patient satisfaction.

46 CFR 201.159 - Decisions; contents and service.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 46 Shipping 8 2012-10-01 2012-10-01 false Decisions; contents and service. 201.159 Section 201.159 Shipping MARITIME ADMINISTRATION, DEPARTMENT OF TRANSPORTATION POLICY, PRACTICE AND PROCEDURE RULES OF PRACTICE AND PROCEDURE Briefs, Requests for Findings, Decisions, Exceptions (Rule 16) § 201.159 Decisions; contents and service. All initial,...

14 CFR 414.9 - Pre-application consultation.

Code of Federal Regulations, 2014 CFR

2014-01-01

... 14 Aeronautics and Space 4 2014-01-01 2014-01-01 false Pre-application consultation. 414.9 Section 414.9 Aeronautics and Space COMMERCIAL SPACE TRANSPORTATION, FEDERAL AVIATION ADMINISTRATION... application process and the potential issues relevant to the FAA's safety approval decision. ...

14 CFR 413.5 - Pre-application consultation.

Code of Federal Regulations, 2013 CFR

2013-01-01

... 413.5 Aeronautics and Space COMMERCIAL SPACE TRANSPORTATION, FEDERAL AVIATION ADMINISTRATION... process and possible issues relevant to the FAA's licensing or permitting decision. Early consultation helps an applicant to identify possible regulatory issues at the planning stage when changes to an...

14 CFR 413.5 - Pre-application consultation.

Code of Federal Regulations, 2011 CFR

2011-01-01

... 413.5 Aeronautics and Space COMMERCIAL SPACE TRANSPORTATION, FEDERAL AVIATION ADMINISTRATION... process and possible issues relevant to the FAA's licensing or permitting decision. Early consultation helps an applicant to identify possible regulatory issues at the planning stage when changes to an...

14 CFR 413.5 - Pre-application consultation.

Code of Federal Regulations, 2012 CFR

2012-01-01

... 413.5 Aeronautics and Space COMMERCIAL SPACE TRANSPORTATION, FEDERAL AVIATION ADMINISTRATION... process and possible issues relevant to the FAA's licensing or permitting decision. Early consultation helps an applicant to identify possible regulatory issues at the planning stage when changes to an...

14 CFR 414.9 - Pre-application consultation.

Code of Federal Regulations, 2011 CFR

2011-01-01

... 14 Aeronautics and Space 4 2011-01-01 2011-01-01 false Pre-application consultation. 414.9 Section 414.9 Aeronautics and Space COMMERCIAL SPACE TRANSPORTATION, FEDERAL AVIATION ADMINISTRATION... application process and the potential issues relevant to the FAA's safety approval decision. ...

14 CFR 414.9 - Pre-application consultation.

Code of Federal Regulations, 2012 CFR

2012-01-01

... 14 Aeronautics and Space 4 2012-01-01 2012-01-01 false Pre-application consultation. 414.9 Section 414.9 Aeronautics and Space COMMERCIAL SPACE TRANSPORTATION, FEDERAL AVIATION ADMINISTRATION... application process and the potential issues relevant to the FAA's safety approval decision. ...

14 CFR 414.9 - Pre-application consultation.

Code of Federal Regulations, 2013 CFR

2013-01-01

... 14 Aeronautics and Space 4 2013-01-01 2013-01-01 false Pre-application consultation. 414.9 Section 414.9 Aeronautics and Space COMMERCIAL SPACE TRANSPORTATION, FEDERAL AVIATION ADMINISTRATION... application process and the potential issues relevant to the FAA's safety approval decision. ...

Outcomes of Ethics Consultations in Adult ICUs: A Systematic Review and Meta-Analysis.

PubMed

Au, Selena S; Couillard, Philippe; Roze des Ordons, Amanda; Fiest, Kirsten M; Lorenzetti, Dianne L; Jette, Nathalie

2018-05-01

Clinical ethics consultation as a mechanism for supporting patients, family, and staff during ethically challenging situations has become standard of care. Despite this, there is a lack of consensus about the effectiveness of clinical ethics consultation consultation in the ICU. We performed a systematic review of outcomes associated with clinical ethics consultation within adult ICUs. We searched MEDLINE, PubMed, Cochrane CENTRAL, Embase, PsycINFO, and Cumulative Index to Nursing and Allied Health Literature from 1984 to May 2017. Two reviewers independently screened articles, assessed eligibility, extracted data, and assessed risk of bias using the Cochrane Collaboration Risk of Bias tool and the Newcastle-Ottawa Scale. Pooled estimates of effect were calculated where possible. We screened 3,970 abstracts and reviewed 325 full-text articles of which 16 met all eligibility criteria. We examined changes in processes and outcomes as a result of clinical ethics consultation in the ICU. Categories of outcomes included user perception, clinical decision, or conflict resolution and resource utilization. The use of clinical ethics consultation in the ICU was associated with positive user experience (383/435 found clinical ethics consultation helpful), although stress and disagreement with clinical ethics consultation recommendations was greater in a subset (113/431 surrogates and providers). Consensus for a clinical decision was more frequently achieved with clinical ethics consultation (odds ratio, 4.09; 95% CI, 1.01-16.55; p = 0.05). Clinical ethics consultation was associated with lower resource utilization including significantly decreased ICU length of stay (mean difference, -4.65 d; 95% CI, -8.86 to -0.44; p = 0.03). Our review identified outcome-based assessment as the predominant measure used to report effectiveness of clinical ethics consultation consultations. In particular, clinical ethics consultation decreased ICU length of stay and increased family and healthcare provider satisfaction. However, using outcome measures as the primary endpoint may not reflect the original intent of the clinical ethics consultation service. Based on our review, we propose a list of process measures that may better capture the key domains of a quality clinical ethics consultation.

Transfer of Patients in a Telestroke Network: What Are the Relevant Factors for Making This Decision?

PubMed

Klingner, Carsten M; Brodoehl, Stefan; Funck, Laura; Klingner, Caroline C; Berrouschot, Jörg; Witte, Otto W; Günther, Albrecht

2018-02-01

Background/Introduction: Current telestroke network consultations are focused on decision-making in the hyperacute stage of stroke management. The two main questions in telestroke consultations are whether thrombolysis should be initiated and whether the patient should be transferred to a hub hospital. Although guidelines exist for initiating intravenous thrombolytic therapy, the question of whether patients should be transferred is far more elusive. In this study, we investigated the factors involved in the decision to transfer stroke patients to a hub hospital. We were particularly interested in identifying factors that promote or impede the transfer of patients. We enrolled 1,615 cases of telestroke consultation of the University Hospital Jena. The two main factors that independently influenced the probability of transferring a patient were the patient's age and the identification of a proximal vessel occlusion. Interestingly, factors such as the severity of symptoms and the time elapsed from symptom onset were not found to have an independent influence on the decision to transfer a patient. The transfer of most patients was justified by the possibility of performing interventional reperfusion therapy. We discuss the effectiveness of the current decision-making process and possible ways to improve decision-making for a more effective selection of patients who would benefit from transfer. The decision-making process to a transfer patient is not standardized and constitutes a trade-off between the intention to treat all possible patients while avoiding the transfer of patients without treatment options.

Judgment and decision making.

PubMed

Mellers, B A; Schwartz, A; Cooke, A D

1998-01-01

For many decades, research in judgment and decision making has examined behavioral violations of rational choice theory. In that framework, rationality is expressed as a single correct decision shared by experimenters and subjects that satisfies internal coherence within a set of preferences and beliefs. Outside of psychology, social scientists are now debating the need to modify rational choice theory with behavioral assumptions. Within psychology, researchers are debating assumptions about errors for many different definitions of rationality. Alternative frameworks are being proposed. These frameworks view decisions as more reasonable and adaptive that previously thought. For example, "rule following." Rule following, which occurs when a rule or norm is applied to a situation, often minimizes effort and provides satisfying solutions that are "good enough," though not necessarily the best. When rules are ambiguous, people look for reasons to guide their decisions. They may also let their emotions take charge. This chapter presents recent research on judgment and decision making from traditional and alternative frameworks.

Extraneous factors in judicial decisions

PubMed Central

Danziger, Shai; Levav, Jonathan; Avnaim-Pesso, Liora

2011-01-01

Are judicial rulings based solely on laws and facts? Legal formalism holds that judges apply legal reasons to the facts of a case in a rational, mechanical, and deliberative manner. In contrast, legal realists argue that the rational application of legal reasons does not sufficiently explain the decisions of judges and that psychological, political, and social factors influence judicial rulings. We test the common caricature of realism that justice is “what the judge ate for breakfast” in sequential parole decisions made by experienced judges. We record the judges’ two daily food breaks, which result in segmenting the deliberations of the day into three distinct “decision sessions.” We find that the percentage of favorable rulings drops gradually from ≈65% to nearly zero within each decision session and returns abruptly to ≈65% after a break. Our findings suggest that judicial rulings can be swayed by extraneous variables that should have no bearing on legal decisions. PMID:21482790

Patients who leave the hospital against medical advice: the role of the psychiatric consultant.

PubMed

Holden, P; Vogtsberger, K N; Mohl, P C; Fuller, D S

1989-01-01

Previous studies have identified characteristics of patients who threaten to leave non-psychiatric units against medical advice, but few have described the role of the psychiatric consultant in the patient's decision. This study compared the medical records of 31 patients who threatened to leave the hospital against medical advice (AMA) and who were seen in consultation with the records of AMA-discharged patients who were not seen by a psychiatric consultant. Most patients who received consultations remained hospitalized or were discharged in regular fashion. Those seen soon after admission were most likely to stay. Patients were more likely to remain hospitalized if the consultant's recommendations had a practical, rather than a psychological, orientation.

Acute knee injuries: use of decision rules for selective radiograph ordering.

PubMed

Tandeter, H B; Shvartzman, P; Stevens, Max A

1999-12-01

Family physicians often encounter patients with acute knee trauma. Radiographs of injured knees are commonly ordered, even though fractures are found in only 6 percent of such patients and emergency department physicians can usually discriminate clinically between fracture and nonfracture. Decision rules have been developed to reduce the unnecessary use of radiologic studies in patients with acute knee injury. The Ottawa knee rules and the Pittsburgh decision rules are the latest guidelines for the selective use of radiographs in knee trauma. Application of these rules may lead to a more efficient evaluation of knee injuries and a reduction in health costs without an increase in adverse outcomes.

Palliative Care Consultations in the Neuro-ICU: A Qualitative Study.

PubMed

Tran, Len N; Back, Anthony L; Creutzfeldt, Claire J

2016-10-01

Integration of palliative care (PC) into the neurological intensive care unit (neuro-ICU) is increasingly recommended, but evidence regarding the best practice is lacking. We conducted a qualitative analysis exploring current practices and key themes of specialist PC consultations in patients admitted to a single neuro-ICU. We retrospectively identified all patients who were admitted to the neuro-ICU for ≥24 h and received a PC consultation between January and August 2014. We reviewed PC consultation notes and neuro-ICU progress notes from the electronic health records of these patients. We performed content analysis on the PC notes. Twenty-five neuro-ICU patients (4 %) received a PC consultation over 8 months with the most prevalent reason of clarifying goals of care. The main distinctions between patients with and those without (n = 580) a PC consultation were ICU length of stay (median 8.2 vs. 2.8 days) and death in the neuro-ICU (56 % vs. 11 %). The most prevalent themes addressed in the PC consultation notes were (1) discussing prognosis, (2) eliciting patient and family values, (3) understanding medical options, and (4) identifying conflict. PC consultations in the neuro-ICU emphasize family coping and decision-making by helping discuss prognosis and exploring patient and family values as well as their ability to understand the medical information. Several features suggest that earlier integration of PC into neuro-ICU care may enhance both coping and the decision-making process.

The Impact of Advice Seekers' Need Salience and Doctors' Communication Style on Attitude and Decision Making: A Web-Based Mammography Consultation Role Play.

PubMed

Fissler, Tim; Bientzle, Martina; Cress, Ulrike; Kimmerle, Joachim

2015-09-08

Patients and advice seekers come to a medical consultation with typical needs, and physicians require adequate communication skills in order to address those needs effectively. It is largely unclear, however, to what extent advice seekers' attitudes toward a medical procedure or their resulting decisions are influenced by a physician's communication that ignores or explicitly takes these needs into account. This experimental study tested how advice seekers' salient needs and doctor's communication styles influenced advice seekers' attitudes toward mammography screening and their decision whether or not to participate in this procedure. One hundred women (age range 20-47 years, mean 25.22, SD 4.71) participated in an interactive role play of an online consultation. During the consultation, a fictitious, program-controlled physician provided information about advantages and disadvantages of mammography screening. The physician either merely communicated factual medical information or made additional comments using a communication style oriented toward advice seekers' typical needs for clarity and well-being. Orthogonal to this experimental treatment, participants' personal needs for clarity and for well-being were either made salient before or after the consultation with a needs questionnaire. We also measured all participants' attitudes toward mammography screening and their hypothetical decisions whether or not to participate before and after the experiment. As assumed, the participants expressed strong needs for clarity (mean 4.57, SD 0.42) and for well-being (mean 4.21, SD 0.54) on 5-point Likert scales. Making these needs salient or not revealed significant interaction effects with the physician's communication style regarding participants' attitude change (F 1,92 =7.23, P=.009, η 2 =.073) and decision making (F 1,92 =4.43, P=.038, η 2 =.046). Those participants whose needs were made salient before the consultation responded to the physician's communication style, while participants without salient needs did not. When the physician used a need-oriented communication style, those participants with salient needs had a more positive attitude toward mammography after the consultation than before (mean 0.13, SD 0.54), while they changed their attitude in a negative direction when confronted with a purely fact-oriented communication style (mean -0.35, SD 0.80). The same applied to decision modification (need-oriented: mean 0.10, SD 0.99; fact-oriented: mean -0.30, SD 0.88). The findings underline the importance of communicating in a need-oriented style with patients and advice seekers who are aware of their personal needs. Ignoring the needs of those people appears to be particularly problematic. So physicians' sensitivity for advice seekers' currently relevant needs is essential. ©Tim Fissler, Martina Bientzle, Ulrike Cress, Joachim Kimmerle. Originally published in JMIR Cancer (http://cancer.jmir.org), 08.09.2015.

Collective decision making and social interaction rules in mixed-species flocks of songbirds

PubMed Central

Farine, Damien R.; Aplin, Lucy M.; Garroway, Colin J.; Mann, Richard P.; Sheldon, Ben C.

2014-01-01

Associations in mixed-species foraging groups are common in animals, yet have rarely been explored in the context of collective behaviour. Despite many investigations into the social and ecological conditions under which individuals should form groups, we still know little about the specific behavioural rules that individuals adopt in these contexts, or whether these can be generalized to heterospecifics. Here, we studied collective behaviour in flocks in a community of five species of woodland passerine birds. We adopted an automated data collection protocol, involving visits by RFID-tagged birds to feeding stations equipped with antennae, over two winters, recording 91 576 feeding events by 1904 individuals. We demonstrated highly synchronized feeding behaviour within patches, with birds moving towards areas of the patch with the largest proportion of the flock. Using a model of collective decision making, we then explored the underlying decision rule birds may be using when foraging in mixed-species flocks. The model tested whether birds used a different decision rule for conspecifics and heterospecifics, and whether the rules used by individuals of different species varied. We found that species differed in their response to the distribution of conspecifics and heterospecifics across foraging patches. However, simulating decisions using the different rules, which reproduced our data well, suggested that the outcome of using different decision rules by each species resulted in qualitatively similar overall patterns of movement. It is possible that the decision rules each species uses may be adjusted to variation in mean species abundance in order for individuals to maintain the same overall flock-level response. This is likely to be important for maintaining coordinated behaviour across species, and to result in quick and adaptive flock responses to food resources that are patchily distributed in space and time. PMID:25214653

Utility of Decision Rules for Transcutaneous Bilirubin Measurements

PubMed Central

Burgos, Anthony E.; Flaherman, Valerie; Chung, Esther K.; Simpson, Elizabeth A.; Goyal, Neera K.; Von Kohorn, Isabelle; Dhepyasuwan, Niramol

2016-01-01

BACKGROUND: Transcutaneous bilirubin (TcB) meters are widely used for screening newborns for jaundice, with a total serum bilirubin (TSB) measurement indicated when the TcB value is classified as “positive” by using a decision rule. The goal of our study was to assess the clinical utility of 3 recommended TcB screening decision rules. METHODS: Paired TcB/TSB measurements were collected at 34 newborn nursery sites. At 27 sites (sample 1), newborns were routinely screened with a TcB measurement. For sample 2, sites that typically screen with TSB levels also obtained a TcB measurement for the study. Three decision rules to define a positive TcB measurement were evaluated: ≥75th percentile on the Bhutani nomogram, 70% of the phototherapy level, and within 3 mg/dL of the phototherapy threshold. The primary outcome was a TSB level at/above the phototherapy threshold. The rate of false-negative TcB screens and percentage of blood draws avoided were calculated for each decision rule. RESULTS: For sample 1, data were analyzed on 911 paired TcB-TSB measurements from a total of 8316 TcB measurements. False-negative rates were <10% with all decision rules; none identified all 31 newborns with a TSB level at/above the phototherapy threshold. The percentage of blood draws avoided ranged from 79.4% to 90.7%. In sample 2, each rule correctly identified all 8 newborns with TSB levels at/above the phototherapy threshold. CONCLUSIONS: Although all of the decision rules can be used effectively to screen newborns for jaundice, each will “miss” some infants with a TSB level at/above the phototherapy threshold. PMID:27244792

Development of the England Wildlife Health Strategy--a framework for decision makers.

PubMed

Hartley, M; Lysons, R

2011-02-12

Diseases in wildlife have been recognised as having the potential to affect human health, livestock health and species conservation. In order to assess and respond to these potential risks in an effective and a proportionate way, the UK Government initiated development of the Wildlife Health Strategy to provide a framework for decision making. The England Wildlife Health Strategy (EWHS) has been developed through extensive consultation. Discussions and negotiations with government departments, agencies, non-governmental public bodies and wildlife organisations were held to obtain advice and input on specific and specialised aspects of wildlife health. A series of workshops to investigate the application of innovative science to wildlife health policy contributed further. A formal public consultation was held that proposed a range of actions to implement the strategy. A summary of responses to this consultation was published in October 2007. The EWHS was published in June 2009 and provides a framework for a generic four-stage approach to wildlife health that can be adopted by decision makers both within and outside government.

Rules and guidelines in clinical practice: a qualitative study in operating theatres of doctors' and nurses' views

PubMed Central

McDonald, R; Waring, J; Harrison, S; Walshe, K; Boaden, R

2005-01-01

Background: The current orthodoxy within patient safety research and policy is characterised by a faith in rules based systems which limit the capacity for individual discretion, and hence fallibility. However, guidelines have been seen as stifling innovation and eroding trust. Our objectives were to explore the attitudes towards guidelines of doctors and nurses working together in surgical teams and to examine the extent to which trusting relationships are maintained in a context governed by explicit rules. Methods: Fourteen consultant grade surgeons of mixed specialty, 12 consultant anaesthetists, and 15 nurses were selected to reflect a range of roles. Participant observation was combined with semi-structured interviews. Results: Doctors' views about the contribution of guidelines to safety and to clinical practice differed from those of nurses. Doctors rejected written rules, instead adhering to the unwritten rules of what constitutes acceptable behaviour for members of the medical profession. In contrast, nurses viewed guideline adherence as synonymous with professionalism and criticised doctors for failing to comply with guidelines. Conclusions: While the creation of a "safety culture" requires a shared set of beliefs, attitudes and norms in relation to what is seen as safe clinical practice, differences of opinion on these issues exist which cannot be easily reconciled since they reflect deeply ingrained beliefs about what constitutes professional conduct. While advocates of standardisation (such as nurses) view doctors as rule breakers, doctors may not necessarily regard guidelines as legitimate or identify with the rules written for them by members of other social groups. Future safety research and policy should attempt to understand the unwritten rules which govern clinical behaviour and examine the ways in which such rules are produced, maintained, and accepted as legitimate. PMID:16076795

Radiology Consultation in the Era of Precision Oncology: A Review of Consultation Models and Services in the Tertiary Setting.

PubMed

DiPiro, Pamela J; Krajewski, Katherine M; Giardino, Angela A; Braschi-Amirfarzan, Marta; Ramaiya, Nikhil H

2017-01-01

The purpose of the article is to describe the various radiology consultation models in the Era of Precision Medicine. Since the inception of our specialty, radiologists have served as consultants to physicians of various disciplines. A variety of radiology consultation services have been described in the literature, including clinical decision support, patient-centric, subspecialty interpretation, and/or some combination of these. In oncology care in particular, case complexity often merits open dialogue with clinical providers. To explore the utility and impact of radiology consultation services in the academic setting, this article will further describe existing consultation models and the circumstances that precipitated their development. The hybrid model successful at our tertiary cancer center is discussed. In addition, the contributions of a consultant radiologist in breast cancer care are reviewed as the archetype of radiology consultation services provided to oncology practitioners.

Belief Function Based Decision Fusion for Decentralized Target Classification in Wireless Sensor Networks

PubMed Central

Zhang, Wenyu; Zhang, Zhenjiang

2015-01-01

Decision fusion in sensor networks enables sensors to improve classification accuracy while reducing the energy consumption and bandwidth demand for data transmission. In this paper, we focus on the decentralized multi-class classification fusion problem in wireless sensor networks (WSNs) and a new simple but effective decision fusion rule based on belief function theory is proposed. Unlike existing belief function based decision fusion schemes, the proposed approach is compatible with any type of classifier because the basic belief assignments (BBAs) of each sensor are constructed on the basis of the classifier’s training output confusion matrix and real-time observations. We also derive explicit global BBA in the fusion center under Dempster’s combinational rule, making the decision making operation in the fusion center greatly simplified. Also, sending the whole BBA structure to the fusion center is avoided. Experimental results demonstrate that the proposed fusion rule has better performance in fusion accuracy compared with the naïve Bayes rule and weighted majority voting rule. PMID:26295399

16 CFR 3.51 - Initial decision.

Code of Federal Regulations, 2010 CFR

2010-01-01

... 16 Commercial Practices 1 2010-01-01 2010-01-01 false Initial decision. 3.51 Section 3.51 Commercial Practices FEDERAL TRADE COMMISSION ORGANIZATION, PROCEDURES AND RULES OF PRACTICE RULES OF PRACTICE FOR ADJUDICATIVE PROCEEDINGS Decision § 3.51 Initial decision. (a) When filed and when effective. The Administrative Law Judge shall file an...

16 CFR 3.52 - Appeal from initial decision.

Code of Federal Regulations, 2010 CFR

2010-01-01

... 16 Commercial Practices 1 2010-01-01 2010-01-01 false Appeal from initial decision. 3.52 Section 3.52 Commercial Practices FEDERAL TRADE COMMISSION ORGANIZATION, PROCEDURES AND RULES OF PRACTICE RULES OF PRACTICE FOR ADJUDICATIVE PROCEEDINGS Decision § 3.52 Appeal from initial decision. (a) Automatic review of cases in which the Commission sough...

49 CFR 1503.631 - Interlocutory appeals.

Code of Federal Regulations, 2010 CFR

2010-10-01

... Rules of Practice in TSA Civil Penalty Actions § 1503.631 Interlocutory appeals. (a) General. Unless otherwise provided in this subpart, a party may not appeal a ruling or decision of the ALJ to the TSA decision maker until the initial decision has been entered on the record. A decision or order of the TSA...

Nurse prescriber-patient consultations: a case study in dermatology.

PubMed

Courtenay, Molly; Carey, Nicola; Stenner, Karen

2009-06-01

This paper is a report of a study exploring the content and processes in consultations between nurse prescribers and patients with dermatological conditions. Communication skills, consultation time, information and follow-up are central to the treatment and management of patients with dermatological conditions. The contribution nurses make to the care of these patients has great potential. A multiple case study was conducted with 10 practice settings across England in which nurses prescribed medicines for patients with dermatological conditions. Data were collected between June 2006 and September 2007 using semi-structured interviews (n = 40), patient questionnaires (n = 165/200) and videotaped observations of nurse consultations (n = 40). Data analysis included thematic analysis, descriptive statistics, chi-square and non-parametric tests. Nurses believed that their holistic approach to assessment, combined with their prescribing knowledge, improved prescribing decisions. Listening and explanation of treatments were aspects of nurse communication that were rated highly by patients. Listening and dealing sensitively with emotions were also aspects of the videotaped consultations that were rated highly by assessors. Nurses were less consistent in providing information about medicines. Triangulated data from this study suggest that nurse prescribing enhances the care of patients with dermatological conditions through improved prescribing decisions. If patients are to be more involved in this decision-making, nurses must give them more information about their medicines. The benefits of prescribing were most evident in the practices of dermatology specialist nurses. Further evidence is required to identify whether prescribing by specialist nurses offers similar benefits in other therapeutic areas.

Is there a need for a clinical decision rule in blunt wrist trauma?

PubMed

van den Brand, Crispijn L; van Leerdam, Roderick H; van Ufford, Jet H M E Quarles; Rhemrev, Steven J

2013-11-01

Blunt wrist trauma is a very common injury in emergency medicine. However, in contrast to other extremity trauma, there is no clinical decision rule for radiography in patients with blunt wrist trauma. The purpose of this study is to describe current practice and to assess the need and feasibility for a clinical decision rule for radiography in patients with blunt wrist trauma. All patients with blunt wrist trauma who presented to our Emergency Department (ED) during a 6-month period were included in this study. Basic demographics were analysed and the radiography ratio was determined. The radiography results were compared for different demographic groups. Current practice and the need and feasibility for a decision rule were evaluated using Stiell's checklist for clinical decision rules. A total of 1019 patients with 1032 blunt wrist injuries presented at our ED in a period of 6 months. In 91.4% of patients, radiographs were taken. In 41.6% of those radiographed, a fracture was visible on plain radiography. Fractures were most common in the paediatric and senior age groups. However, even in the lower-risk groups we observed a fracture incidence of about 20%. There is no need for a clinical decision rule for radiography in patients with blunt wrist trauma because the fracture ratio is high. Neither does it seem feasible to develop a highly sensitive and efficient decision rule. Therefore, the authors recommend radiography in all patients with blunt wrist trauma presenting to the ED. Copyright © 2013 Elsevier Ltd. All rights reserved.

Decision Regulation Impact Statement for Changes to the National Quality Framework

ERIC Educational Resources Information Center

Education Council, 2017

2017-01-01

The purpose of this Decision Regulation Impact Statement (Decision RIS) is to recommend preferred options for improving the National Quality Framework for Early Childhood Education and Care. The Decision RIS follows the public release of the Consultation RIS and incorporates stakeholders' views and comments received during the ten week stakeholder…

The Effects of Decision-Making Style on Openness and Satisfaction within Japanese Organizations.

ERIC Educational Resources Information Center

Stewart, Lea P.; And Others

1986-01-01

Examines the influence of decision-making style on communication openness and satisfaction in Japanese organizations. Results of a survey indicated that Japanese employees preferred persuasive or consultative managerial decision-making styles and were more satisfied when their preferred decision-making style and the style of their manager were…

A detailed comparison of optimality and simplicity in perceptual decision-making

PubMed Central

Shen, Shan; Ma, Wei Ji

2017-01-01

Two prominent ideas in the study of decision-making have been that organisms behave near-optimally, and that they use simple heuristic rules. These principles might be operating in different types of tasks, but this possibility cannot be fully investigated without a direct, rigorous comparison within a single task. Such a comparison was lacking in most previous studies, because a) the optimal decision rule was simple; b) no simple suboptimal rules were considered; c) it was unclear what was optimal, or d) a simple rule could closely approximate the optimal rule. Here, we used a perceptual decision-making task in which the optimal decision rule is well-defined and complex, and makes qualitatively distinct predictions from many simple suboptimal rules. We find that all simple rules tested fail to describe human behavior, that the optimal rule accounts well for the data, and that several complex suboptimal rules are indistinguishable from the optimal one. Moreover, we found evidence that the optimal model is close to the true model: first, the better the trial-to-trial predictions of a suboptimal model agree with those of the optimal model, the better that suboptimal model fits; second, our estimate of the Kullback-Leibler divergence between the optimal model and the true model is not significantly different from zero. When observers receive no feedback, the optimal model still describes behavior best, suggesting that sensory uncertainty is implicitly represented and taken into account. Beyond the task and models studied here, our results have implications for best practices of model comparison. PMID:27177259

Decision technology.

PubMed

Edwards, W; Fasolo, B

2001-01-01

This review is about decision technology-the rules and tools that help us make wiser decisions. First, we review the three rules that are at the heart of most traditional decision technology-multi-attribute utility, Bayes' theorem, and subjective expected utility maximization. Since the inception of decision research, these rules have prescribed how we should infer values and probabilities and how we should combine them to make better decisions. We suggest how to make best use of all three rules in a comprehensive 19-step model. The remainder of the review explores recently developed tools of decision technology. It examines the characteristics and problems of decision-facilitating sites on the World Wide Web. Such sites now provide anyone who can use a personal computer with access to very sophisticated decision-aiding tools structured mainly to facilitate consumer decision making. It seems likely that the Web will be the mode by means of which decision tools will be distributed to lay users. But methods for doing such apparently simple things as winnowing 3000 options down to a more reasonable number, like 10, contain traps for unwary decision technologists. The review briefly examines Bayes nets and influence diagrams-judgment and decision-making tools that are available as computer programs. It very briefly summarizes the state of the art of eliciting probabilities from experts. It concludes that decision tools will be as important in the 21st century as spreadsheets were in the 20th.

A study of some nine-element decision rules. [for multispectral recognition of remote sensing

NASA Technical Reports Server (NTRS)

Richardson, W.

1974-01-01

A nine-element rule is one that makes a classification decision for each pixel based on data from that pixel and its eight immediate neighbors. Three such rules, all fast and simple to use, are defined and tested. All performed substantially better on field interiors than the best one-point rule. Qualitative results indicate that fine detail and contradictory testimony tend to be overlooked by the rules.

76 FR 61425 - Self-Regulatory Organizations; EDGA Exchange, Inc.; Notice of Filing of Proposed Rule Change by...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-10-04

... All Stocks Due to Extraordinary Market Volatility September 28, 2011. Pursuant to Section 19(b)(1) of... determining when trading in all stocks will be halted due to extraordinary market volatility. The text of the... volatility. The Exchange is proposing this rule change in consultation with other equity, options and futures...

78 FR 42875 - Community Right-to-Know; Adoption of 2012 North American Industry Classification System (NAICS...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-07-18

....regulations.gov or email. The www.regulations.gov Web site is an ``anonymous access'' system, which means EPA.../ . SUPPLEMENTARY INFORMATION: I. Why is EPA using a direct final rule? EPA is publishing this rule without a prior... entity, consult the person listed in the FOR FURTHER INFORMATION CONTACT section. III. What should I...

77 FR 64369 - Self-Regulatory Organizations; The NASDAQ Stock Market LLC; Notice of Filing of Proposed Rule...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-10-19

... securities laws. It is suggested that the Company consult with corporate/securities counsel in assessing its... SECURITIES AND EXCHANGE COMMISSION [Release No. 34-68053; File No. SR-NASDAQ-2012-118] Self... Section 19(b)(1) of the Securities Exchange Act of 1934 (``Act''),\\1\\ and Rule 19b-4 thereunder,\\2\\ notice...

A Data Model for Teleconsultation in Managing High-Risk Pregnancies: Design and Preliminary Evaluation

PubMed Central

Deldar, Kolsoum

2017-01-01

Background Teleconsultation is a guarantor for virtual supervision of clinical professors on clinical decisions made by medical residents in teaching hospitals. Type, format, volume, and quality of exchanged information have a great influence on the quality of remote clinical decisions or tele-decisions. Thus, it is necessary to develop a reliable and standard model for these clinical relationships. Objective The goal of this study was to design and evaluate a data model for teleconsultation in the management of high-risk pregnancies. Methods This study was implemented in three phases. In the first phase, a systematic review, a qualitative study, and a Delphi approach were done in selected teaching hospitals. Systematic extraction and localization of diagnostic items to develop the tele-decision clinical archetypes were performed as the second phase. Finally, the developed model was evaluated using predefined consultation scenarios. Results Our review study has shown that present medical consultations have no specific structure or template for patient information exchange. Furthermore, there are many challenges in the remote medical decision-making process, and some of them are related to the lack of the mentioned structure. The evaluation phase of our research has shown that data quality (P<.001), adequacy (P<.001), organization (P<.001), confidence (P<.001), and convenience (P<.001) had more scores in archetype-based consultation scenarios compared with routine-based ones. Conclusions Our archetype-based model could acquire better and higher scores in the data quality, adequacy, organization, confidence, and convenience dimensions than ones with routine scenarios. It is probable that the suggested archetype-based teleconsultation model may improve the quality of physician-physician remote medical consultations. PMID:29242181

28 CFR 115.317 - Hiring and promotion decisions.

Code of Federal Regulations, 2012 CFR

2012-07-01

... records check; (2) Consult any child abuse registry maintained by the State or locality in which the... also perform a criminal background records check, and consult applicable child abuse registries, before... sexual abuse in a prison, jail, lockup, community confinement facility, juvenile facility, or other...

28 CFR 115.317 - Hiring and promotion decisions.

Code of Federal Regulations, 2013 CFR

2013-07-01

... records check; (2) Consult any child abuse registry maintained by the State or locality in which the... also perform a criminal background records check, and consult applicable child abuse registries, before... sexual abuse in a prison, jail, lockup, community confinement facility, juvenile facility, or other...

28 CFR 115.317 - Hiring and promotion decisions.

Code of Federal Regulations, 2014 CFR

2014-07-01

... records check; (2) Consult any child abuse registry maintained by the State or locality in which the... also perform a criminal background records check, and consult applicable child abuse registries, before... sexual abuse in a prison, jail, lockup, community confinement facility, juvenile facility, or other...

Wasting the doctor's time? A video-elicitation interview study with patients in primary care.

PubMed

Llanwarne, Nadia; Newbould, Jennifer; Burt, Jenni; Campbell, John L; Roland, Martin

2017-03-01

Reaching a decision about whether and when to visit the doctor can be a difficult process for the patient. An early visit may cause the doctor to wonder why the patient chose to consult when the disease was self-limiting and symptoms would have settled without medical input. A late visit may cause the doctor to express dismay that the patient waited so long before consulting. In the UK primary care context of constrained resources and government calls for cautious healthcare spending, there is all the more pressure on both doctor and patient to meet only when necessary. A tendency on the part of health professionals to judge patients' decisions to consult as appropriate or not is already described. What is less well explored is the patient's experience of such judgment. Drawing on data from 52 video-elicitation interviews conducted in the English primary care setting, the present paper examines how patients seek to legitimise their decision to consult, and their struggles in doing so. The concern over wasting the doctor's time is expressed repeatedly through patients' narratives. Referring to the sociological literature, the history of 'trivia' in defining the role of general practice is discussed, and current public discourses seeking to assist the patient in developing appropriate consulting behaviour are considered and problematised. Whilst the patient is expected to have sufficient insight to inform timely consulting behaviour, it becomes clear that any attempt on the part of doctor or patient to define legitimate help-seeking is in fact elusive. Despite this, a significant moral dimension to what is deemed appropriate consulting by doctors and patients remains. The notion of candidacy is suggested as a suitable framework and way forward for encompassing these struggles to negotiate eligibility for medical time. Copyright © 2017 The Authors. Published by Elsevier Ltd.. All rights reserved.

[Bioethics in medical institutions--new custom or help? The example of clinical ethics consultation at a University Medical Center].

PubMed

Richter, G

2014-08-01

Although ethics committees are well established in the medical sciences for human clinical trials, animal research and scientific integrity, the development of clinical ethics in German hospitals started much later during the first decade of the twenty-first century. Clinical ethics consultation should be pragmatic and problem-centered and can be defined as an ethically qualified and informed conflict management within a given legal framework to deal with and resolve value-driven, normative problems in the care of patients. Clinical ethics consultations enable shared clinical decision-making of all parties (e.g. clinicians, patients, family and surrogates) involved in a particular patient's care. The clinical ethicist does not act as an ethics expert by making independent recommendations or decisions; therefore, the focus is different from other medical consultants. Ethics consultation was first established by healthcare ethics committees (HEC) or clinical ethics consultation (CEC) groups which were called in to respond to an ethically problematic situation. To avoid ethical dilemmas or crises and to act preventively with regard to ethical issues in individual patients, an ethics liaison service is an additional option to ethics case consultations which take place on a regular basis by scheduled ethics rounds during the normal ward rounds. The presence of the ethicist offers some unique advantages: it allows early recognition of even minor ethical problems and accommodates the dynamics of ethical and clinical goal-setting in the course of patient care. Most importantly, regular and non-authoritative participation of the ethicist in normal ward rounds allows continuous ethical education of the staff within the everyday clinical routine. By facilitating clinical ethical decision-making, the ethicist seeks to empower physicians and medical staff to deal appropriately with ethical problems by themselves. Because of this proactive approach, the ethics liaison service can make a significant contribution to preventative ethics in reducing the number of emerging ethical problems to the satisfaction of all parties involved.

Concurrent approach for evolving compact decision rule sets

NASA Astrophysics Data System (ADS)

Marmelstein, Robert E.; Hammack, Lonnie P.; Lamont, Gary B.

1999-02-01

The induction of decision rules from data is important to many disciplines, including artificial intelligence and pattern recognition. To improve the state of the art in this area, we introduced the genetic rule and classifier construction environment (GRaCCE). It was previously shown that GRaCCE consistently evolved decision rule sets from data, which were significantly more compact than those produced by other methods (such as decision tree algorithms). The primary disadvantage of GRaCCe, however, is its relatively poor run-time execution performance. In this paper, a concurrent version of the GRaCCE architecture is introduced, which improves the efficiency of the original algorithm. A prototype of the algorithm is tested on an in- house parallel processor configuration and the results are discussed.

Prophylactic Mastectomy: Impact and Intervention

DTIC Science & Technology

2000-10-01

self - esteem marital and family relationships etc. A psychological consultation offered to women making this irreversible decision would likely improve decision-making and subsequent coping. The design of this consultation is best informed by data about physical and emotional effects of surgery from women who have had this procedure. This project aims to gather such data through taped telephone interviews with women who had both breasts removed prophylactically (N-25) women with cancer in one breast who had both breasts removed (N-5O) and women considering PM (N-5O). We aim

Patient and provider perspectives on the design and implementation of an electronic consultation system for kidney care delivery in Canada: a focus group study.

PubMed

Bello, Aminu K; Molzahn, Anita E; Girard, Louis P; Osman, Mohamed A; Okpechi, Ikechi G; Glassford, Jodi; Thompson, Stephanie; Keely, Erin; Liddy, Clare; Manns, Braden; Jinda, Kailash; Klarenbach, Scott; Hemmelgarn, Brenda; Tonelli, Marcello

2017-03-02

We assessed stakeholder perceptions on the use of an electronic consultation system (e-Consult) to improve the delivery of kidney care in Alberta. We aim to identify acceptability, barriers and facilitators to the use of an e-Consult system for ambulatory kidney care delivery. This was a qualitative focus group study using a thematic analysis design. Eight focus groups were held in four locations in the province of Alberta, Canada. In total, there were 72 participants in two broad stakeholder categories: patients (including patients' relatives) and providers (including primary care physicians, nephrologists, other care providers and policymakers). The e-Consult system was generally acceptable across all stakeholder groups. The key barriers identified were length of time required for referring physicians to complete the e-Consult due to lack of integration with current electronic medical records, and concerns that increased numbers of requests might overwhelm nephrologists and lead to a delayed response or an unsustainable system. The key facilitators identified were potential improvement of care coordination, dissemination of best practice through an educational platform, comprehensive data to make decisions without the need for face-to-face consultation, timely feedback to primary care providers, timeliness/reduced delays for patients' rapid triage and identification of cases needing urgent care and improved access to information to facilitate decision-making in patient care. Stakeholder perceptions regarding the e-Consult system were favourable, and the key barriers and facilitators identified will be considered in design and implementation of an acceptable and sustainable electronic consultation system for kidney care delivery. 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/.

Automatic rule generation for high-level vision

NASA Technical Reports Server (NTRS)

Rhee, Frank Chung-Hoon; Krishnapuram, Raghu

1992-01-01

A new fuzzy set based technique that was developed for decision making is discussed. It is a method to generate fuzzy decision rules automatically for image analysis. This paper proposes a method to generate rule-based approaches to solve problems such as autonomous navigation and image understanding automatically from training data. The proposed method is also capable of filtering out irrelevant features and criteria from the rules.

14 CFR 14.27 - Decision.

Code of Federal Regulations, 2011 CFR

2011-01-01

... 14 Aeronautics and Space 1 2011-01-01 2011-01-01 false Decision. 14.27 Section 14.27 Aeronautics and Space FEDERAL AVIATION ADMINISTRATION, DEPARTMENT OF TRANSPORTATION PROCEDURAL RULES RULES IMPLEMENTING THE EQUAL ACCESS TO JUSTICE ACT OF 1980 Procedures for Considering Applications § 14.27 Decision...

14 CFR 14.27 - Decision.

Code of Federal Regulations, 2014 CFR

2014-01-01

... 14 Aeronautics and Space 1 2014-01-01 2014-01-01 false Decision. 14.27 Section 14.27 Aeronautics and Space FEDERAL AVIATION ADMINISTRATION, DEPARTMENT OF TRANSPORTATION PROCEDURAL RULES RULES IMPLEMENTING THE EQUAL ACCESS TO JUSTICE ACT OF 1980 Procedures for Considering Applications § 14.27 Decision...

14 CFR 14.27 - Decision.

Code of Federal Regulations, 2010 CFR

2010-01-01

... 14 Aeronautics and Space 1 2010-01-01 2010-01-01 false Decision. 14.27 Section 14.27 Aeronautics and Space FEDERAL AVIATION ADMINISTRATION, DEPARTMENT OF TRANSPORTATION PROCEDURAL RULES RULES IMPLEMENTING THE EQUAL ACCESS TO JUSTICE ACT OF 1980 Procedures for Considering Applications § 14.27 Decision...

14 CFR 14.27 - Decision.

Code of Federal Regulations, 2013 CFR

2013-01-01

... 14 Aeronautics and Space 1 2013-01-01 2013-01-01 false Decision. 14.27 Section 14.27 Aeronautics and Space FEDERAL AVIATION ADMINISTRATION, DEPARTMENT OF TRANSPORTATION PROCEDURAL RULES RULES IMPLEMENTING THE EQUAL ACCESS TO JUSTICE ACT OF 1980 Procedures for Considering Applications § 14.27 Decision...

14 CFR 14.27 - Decision.

Code of Federal Regulations, 2012 CFR

2012-01-01

... 14 Aeronautics and Space 1 2012-01-01 2012-01-01 false Decision. 14.27 Section 14.27 Aeronautics and Space FEDERAL AVIATION ADMINISTRATION, DEPARTMENT OF TRANSPORTATION PROCEDURAL RULES RULES IMPLEMENTING THE EQUAL ACCESS TO JUSTICE ACT OF 1980 Procedures for Considering Applications § 14.27 Decision...

Pharmacy student decision making in over-the-counter medicine supply: A critical incident study.

PubMed

McMillan, Sara S; Thangarajah, Thachaayini; Anderson, Claire; Kelly, Fiona

2017-09-28

Various factors influence decision making in over-the-counter (OTC) medicine consultations, yet limited studies have focused, in-depth, on the thought process of pharmacy staff. This includes pharmacy students as pharmacists-in-training. To explore the factors that influence pharmacy students' decisions in relation to OTC consultations and choice of OTC medicine/s. Semi-structured interviews using the critical incident technique were undertaken with ten pharmacy students in Australia, who also worked as part-time pharmacy staff. Nine key themes were identified to influence pharmacy student decision making in OTC consultations, including customer response, confidence and scope of practice. Product requests were reported as more challenging due to customer expectations and experiences in other pharmacies, states or countries. Although negative customer response influenced some students to supply medicines in contradiction of evidence, an overarching concern for safety meant that a medicine was only supplied if unlikely to cause harm. Students reported developing confidence in OTC decision making more from real-life practice than university training; greater confidence was identified for inquiries more frequently experienced in the pharmacy. Students perceived that customers had assumptions around support staff, and were happier to talk to students than assistants. This study further identified that OTC decision making is a complex process for pharmacy students. Additional opportunities for experiential learning within this area are suggested, such as work-based placements or in-class activities such as role-plays with simulated patients. Copyright © 2017 Elsevier Inc. All rights reserved.

Measuring patients' help-seeking decisions: results of a pilot-scale survey using a newly developed tool.

PubMed

Davies, Gareth; Fazey, Della

2014-04-01

The aim of the study was to establish the scale and cost of ineffectively made consultations by self-referring patients across three North Wales primary care practices for 'day-to-day' conditions. Little evidence exists of the scale of ineffectively made day-to-day help-seeking by self-referral patients. Examination of this issue is compromised by the use of traditional language to describe help-seeking, which is subjective and of limited use. There is little understanding about help-seeking for day-to-day conditions. Most research on help-seeking behaviour has considered help-seeking for specific services; specific cohorts; or specific conditions, rather than help-seeking for day-to-day conditions. A survey of all routine consultations made at four general practices in North Wales over a one-week period was conducted. Using objective definitional parameters classifying routine consultations as either effectively or ineffectively made, we measured the scale of ineffective help-seeking. General practitioners categorised consultations as either effective or ineffective. Ineffectively made consultations were categorised as follows: potentially avoidable; made with the wrong healthcare professional; or made at the wrong time. A total of 22 GPs made 1217 routine consultations for day-to-day symptoms, of which 24% were ineffectively made. Fifteen percent of consultations were potentially avoidable. Potentially avoidable consultations alone may be costing the NHS £87.85 million annually. The ineffective use of limited and scarce healthcare resources should be examined. Patient outcome may be potentially compromised directly by poor help-seeking decisions but also by ineffective use of resources.

Emergency medicine and psychiatry agreement on diagnosis and disposition of emergency department patients with behavioral emergencies.

PubMed

Douglass, Amy M; Luo, John; Baraff, Larry J

2011-04-01

The objective was to determine the level of agreement between emergency physicians (EPs) and consulting psychiatrists in their diagnosis and disposition of emergency department (ED) patients with behavioral emergencies. The authors conducted a prospective study at a university teaching hospital ED with an annual census of approximately 45,000 patients. During study hours, each time a psychiatric consultation was requested, the emergency medicine (EM) and consulting psychiatry residents were asked to fill out similar short questionnaires concerning their diagnoses and disposition decisions after they consulted with their attending physicians. EM and psychiatry residents were blinded to the other's assessment of the patient. Residents were asked about their evaluation of patients regarding: 1) psychiatric assessments, 2) if the patients presented a danger to themselves or others or were gravely disabled, and 3) the need for emergency psychiatric hospitalization. A total of 408 resident physician pairs were enrolled in the study. Patients ranged in age from 5 to 92 years, with a median age of 31 years; 50% were female. The most common psychiatric assessments, as evaluated by either EPs, consulting psychiatrists, or both, were mood disorder (66%), suicidality (57%), drug/alcohol abuse (26%), and psychosis (25%). Seventy-three percent were admitted for acute psychiatric hospitalization. Agreement between EPs and psychiatrists was 67% for presence of mood disorder, 82% for suicidality, 82% for drug/alcohol abuse, 85% for psychosis, and 85% for grave disability. There was 67% agreement regarding patient eligibility for involuntary psychiatric hold. EPs felt confident enough to make disposition decisions 87% of the time; for these patients there was 76% agreement with consulting psychiatrists about the final disposition decision. The 67% agreement between EPs and consulting psychiatrists regarding need for involuntary hold, and 76% agreement regarding final disposition, demonstrate a substantial disagreement between EPs and psychiatrists regarding management and disposition of ED patients with psychiatric complaints. Further studies with patient follow-up are needed to determine the accuracy of the ED assessments by both EPs and consulting psychiatrists. © 2011 by the Society for Academic Emergency Medicine.

14 CFR 16.227 - Standard of proof.

Code of Federal Regulations, 2011 CFR

2011-01-01

... 14 Aeronautics and Space 1 2011-01-01 2011-01-01 false Standard of proof. 16.227 Section 16.227 Aeronautics and Space FEDERAL AVIATION ADMINISTRATION, DEPARTMENT OF TRANSPORTATION PROCEDURAL RULES RULES OF... hearing officer shall issue an initial decision or shall rule in a party's favor only if the decision or...

14 CFR 16.227 - Standard of proof.

Code of Federal Regulations, 2010 CFR

2010-01-01

... 14 Aeronautics and Space 1 2010-01-01 2010-01-01 false Standard of proof. 16.227 Section 16.227 Aeronautics and Space FEDERAL AVIATION ADMINISTRATION, DEPARTMENT OF TRANSPORTATION PROCEDURAL RULES RULES OF... hearing officer shall issue an initial decision or shall rule in a party's favor only if the decision or...

14 CFR 16.227 - Standard of proof.

Code of Federal Regulations, 2012 CFR

2012-01-01

... 14 Aeronautics and Space 1 2012-01-01 2012-01-01 false Standard of proof. 16.227 Section 16.227 Aeronautics and Space FEDERAL AVIATION ADMINISTRATION, DEPARTMENT OF TRANSPORTATION PROCEDURAL RULES RULES OF... hearing officer shall issue an initial decision or shall rule in a party's favor only if the decision or...

14 CFR 16.227 - Standard of proof.

Code of Federal Regulations, 2013 CFR

2013-01-01

... 14 Aeronautics and Space 1 2013-01-01 2013-01-01 false Standard of proof. 16.227 Section 16.227 Aeronautics and Space FEDERAL AVIATION ADMINISTRATION, DEPARTMENT OF TRANSPORTATION PROCEDURAL RULES RULES OF... hearing officer shall issue an initial decision or shall rule in a party's favor only if the decision or...

Clinical versus actuarial judgment.

PubMed

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

1989-03-31

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

20 CFR 220.62 - Reviewing reports of consultative examinations.

Code of Federal Regulations, 2010 CFR

2010-04-01

... decision-making in terms of the impairment it assesses. (2) Whether the report is internally consistent... 20 Employees' Benefits 1 2010-04-01 2010-04-01 false Reviewing reports of consultative examinations. 220.62 Section 220.62 Employees' Benefits RAILROAD RETIREMENT BOARD REGULATIONS UNDER THE...

A simple threshold rule is sufficient to explain sophisticated collective decision-making.

PubMed

Robinson, Elva J H; Franks, Nigel R; Ellis, Samuel; Okuda, Saki; Marshall, James A R

2011-01-01

Decision-making animals can use slow-but-accurate strategies, such as making multiple comparisons, or opt for simpler, faster strategies to find a 'good enough' option. Social animals make collective decisions about many group behaviours including foraging and migration. The key to the collective choice lies with individual behaviour. We present a case study of a collective decision-making process (house-hunting ants, Temnothorax albipennis), in which a previously proposed decision strategy involved both quality-dependent hesitancy and direct comparisons of nests by scouts. An alternative possible decision strategy is that scouting ants use a very simple quality-dependent threshold rule to decide whether to recruit nest-mates to a new site or search for alternatives. We use analytical and simulation modelling to demonstrate that this simple rule is sufficient to explain empirical patterns from three studies of collective decision-making in ants, and can account parsimoniously for apparent comparison by individuals and apparent hesitancy (recruitment latency) effects, when available nests differ strongly in quality. This highlights the need to carefully design experiments to detect individual comparison. We present empirical data strongly suggesting that best-of-n comparison is not used by individual ants, although individual sequential comparisons are not ruled out. However, by using a simple threshold rule, decision-making groups are able to effectively compare options, without relying on any form of direct comparison of alternatives by individuals. This parsimonious mechanism could promote collective rationality in group decision-making.

48 CFR 2009.570-1 - Scope of policy.

Code of Federal Regulations, 2010 CFR

2010-10-01

... competitive advantage? (c) The conflict of interest rule contained in this subpart applies to contractors and... of consulting services through the personnel appointment process. NRC agreements with other Govern...

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

PubMed

Linan, Margaret K; Sottara, Davide; Freimuth, Robert R

2015-01-01

Pharmacogenomics (PGx) guidelines contain drug-gene relationships, therapeutic and clinical recommendations from which clinical decision support (CDS) rules can be extracted, rendered and then delivered through clinical decision support systems (CDSS) to provide clinicians with just-in-time information at the point of care. Several tools exist that can be used to generate CDS rules that are based on computer interpretable guidelines (CIG), but none have been previously applied to the PGx domain. We utilized the Unified Modeling Language (UML), the Health Level 7 virtual medical record (HL7 vMR) model, and standard terminologies to represent the semantics and decision logic derived from a PGx guideline, which were then mapped to the Health eDecisions (HeD) schema. The modeling and extraction processes developed here demonstrate how structured knowledge representations can be used to support the creation of shareable CDS rules from PGx guidelines.

Inside the black box: starting to uncover the underlying decision rules used in one-by-one expert assessment of occupational exposure in case-control studies

PubMed Central

Wheeler, David C.; Burstyn, Igor; Vermeulen, Roel; Yu, Kai; Shortreed, Susan M.; Pronk, Anjoeka; Stewart, Patricia A.; Colt, Joanne S.; Baris, Dalsu; Karagas, Margaret R.; Schwenn, Molly; Johnson, Alison; Silverman, Debra T.; Friesen, Melissa C.

2014-01-01

Objectives Evaluating occupational exposures in population-based case-control studies often requires exposure assessors to review each study participants' reported occupational information job-by-job to derive exposure estimates. Although such assessments likely have underlying decision rules, they usually lack transparency, are time-consuming and have uncertain reliability and validity. We aimed to identify the underlying rules to enable documentation, review, and future use of these expert-based exposure decisions. Methods Classification and regression trees (CART, predictions from a single tree) and random forests (predictions from many trees) were used to identify the underlying rules from the questionnaire responses and an expert's exposure assignments for occupational diesel exhaust exposure for several metrics: binary exposure probability and ordinal exposure probability, intensity, and frequency. Data were split into training (n=10,488 jobs), testing (n=2,247), and validation (n=2,248) data sets. Results The CART and random forest models' predictions agreed with 92–94% of the expert's binary probability assignments. For ordinal probability, intensity, and frequency metrics, the two models extracted decision rules more successfully for unexposed and highly exposed jobs (86–90% and 57–85%, respectively) than for low or medium exposed jobs (7–71%). Conclusions CART and random forest models extracted decision rules and accurately predicted an expert's exposure decisions for the majority of jobs and identified questionnaire response patterns that would require further expert review if the rules were applied to other jobs in the same or different study. This approach makes the exposure assessment process in case-control studies more transparent and creates a mechanism to efficiently replicate exposure decisions in future studies. PMID:23155187

Determining rules for closing customer service centers: A public utility company's fuzzy decision

NASA Technical Reports Server (NTRS)

Dekorvin, Andre; Shipley, Margaret F.

1992-01-01

In the present work, we consider the general problem of knowledge acquisition under uncertainty. A commonly used method is to learn by examples. We observe how the expert solves specific cases and from this infer some rules by which the decision was made. Unique to this work is the fuzzy set representation of the conditions or attributes upon which the decision make may base his fuzzy set decision. From our examples, we infer certain and possible rules containing fuzzy terms. It should be stressed that the procedure determines how closely the expert follows the conditions under consideration in making his decision. We offer two examples pertaining to the possible decision to close a customer service center of a public utility company. In the first example, the decision maker does not follow too closely the conditions. In the second example, the conditions are much more relevant to the decision of the expert.

Validating the TeleStroke Mimic Score: A Prediction Rule for Identifying Stroke Mimics Evaluated Over Telestroke Networks.

PubMed

Ali, Syed F; Hubert, Gordian J; Switzer, Jeffrey A; Majersik, Jennifer J; Backhaus, Roland; Shepard, L Wylie; Vedala, Kishore; Schwamm, Lee H

2018-03-01

Up to 30% of acute stroke evaluations are deemed stroke mimics, and these are common in telestroke as well. We recently published a risk prediction score for use during telestroke encounters to differentiate stroke mimics from ischemic cerebrovascular disease derived and validated in the Partners TeleStroke Network. Using data from 3 distinct US and European telestroke networks, we sought to externally validate the TeleStroke Mimic (TM) score in a broader population. We evaluated the TM score in 1930 telestroke consults from the University of Utah, Georgia Regents University, and the German TeleMedical Project for Integrative Stroke Care Network. We report the area under the curve in receiver-operating characteristic curve analysis with 95% confidence interval for our previously derived TM score in which lower TM scores correspond with a higher likelihood of being a stroke mimic. Based on final diagnosis at the end of the telestroke consultation, there were 630 of 1930 (32.6%) stroke mimics in the external validation cohort. All 6 variables included in the score were significantly different between patients with ischemic cerebrovascular disease versus stroke mimics. The TM score performed well (area under curve, 0.72; 95% confidence interval, 0.70-0.73; P <0.001), similar to our prior external validation in the Partners National Telestroke Network. The TM score's ability to predict the presence of a stroke mimic during telestroke consultation in these diverse cohorts was similar to its performance in our original cohort. Predictive decision-support tools like the TM score may help highlight key clinical differences between mimics and patients with stroke during complex, time-critical telestroke evaluations. © 2018 American Heart Association, Inc.

How communication affects prescription decisions in consultations for acute illness in children: a systematic review and meta-ethnography

PubMed Central

2014-01-01

Background Communication within primary care consultations for children with acute illness can be problematic for parents and clinicians, with potential misunderstandings contributing to over–prescription of antibiotics. This review aimed to synthesise the evidence in relation to communication and decision making in consultations for children with common acute illness. Methods A systematic search of MEDLINE, EMBASE, CINAHL, PsycINFO, SSCI, SIGLE, Dissertation Express and NHS economic evaluation databases was conducted. Studies of primary care settings in high income countries which made direct observations of consultations and reported qualitative data were included. Included studies were appraised using the process recommended by the Cochrane Qualitative Methods Group. Credibility was assessed as high for most studies but transferability was usually assessed low or unclear. Data were synthesised using a meta–ethnographic approach. Results Thirty–five papers and 2 theses reporting on 13 studies were included, 7 of these focussed on children with respiratory tract infections (RTI) and the remaining 6 included children with any presenting illness. Parent communication focussed on their concerns and information needs, whereas clinician communication focussed on diagnosis and treatment decisions. During information exchanges, parents often sought to justify the need for the consultation, while clinicians frequently used problem minimising language, resulting in parents and clinicians sometimes talking at cross–purposes. In the context of RTIs, a range of parent communication behaviours were interpreted by clinicians as indicating an expectation for antibiotics; however, most were ambiguous and could also be interpreted as raising concerns or requests for further information. The perceived expectation for antibiotics often changed clinician decision making into clinician–parent negotiation. Conclusions Misunderstandings occurred due to parents and clinicians talking at cross purposes about the ‘seriousness’ of the illness and because parents’ expressions of concern or requests for additional information were sometimes perceived as a challenge to the clinicians’ diagnosis or treatment decision. This modifiable problem may be an important contribution to the unnecessary and unwanted prescribing of antibiotics. Primary care clinicians should be offered training to understand parent communication primarily as expressions of concern or attempts at understanding and always to check rather than infer parental expectations. PMID:24708839

14 CFR 302.607 - Decision by administrative law judge.

Code of Federal Regulations, 2014 CFR

2014-01-01

... (AVIATION PROCEEDINGS) PROCEDURAL REGULATIONS RULES OF PRACTICE IN PROCEEDINGS Rules Applicable to... judge shall issue a decision recommending a disposition of a complaint or request for determination...

14 CFR 302.607 - Decision by administrative law judge.

Code of Federal Regulations, 2013 CFR

2013-01-01

... (AVIATION PROCEEDINGS) PROCEDURAL REGULATIONS RULES OF PRACTICE IN PROCEEDINGS Rules Applicable to... judge shall issue a decision recommending a disposition of a complaint or request for determination...

14 CFR 302.607 - Decision by administrative law judge.

Code of Federal Regulations, 2010 CFR

2010-01-01

... (AVIATION PROCEEDINGS) PROCEDURAL REGULATIONS RULES OF PRACTICE IN PROCEEDINGS Rules Applicable to... judge shall issue a decision recommending a disposition of a complaint or request for determination...

14 CFR 302.607 - Decision by administrative law judge.

Code of Federal Regulations, 2011 CFR

2011-01-01

... (AVIATION PROCEEDINGS) PROCEDURAL REGULATIONS RULES OF PRACTICE IN PROCEEDINGS Rules Applicable to... judge shall issue a decision recommending a disposition of a complaint or request for determination...

14 CFR 302.607 - Decision by administrative law judge.

Code of Federal Regulations, 2012 CFR

2012-01-01

... (AVIATION PROCEEDINGS) PROCEDURAL REGULATIONS RULES OF PRACTICE IN PROCEEDINGS Rules Applicable to... judge shall issue a decision recommending a disposition of a complaint or request for determination...

Perspectives of adolescents on decision making about participation in a biobank study: a pilot study.

PubMed

Grootens-Wiegers, Petronella; Visser, Eline G; van Rossum, Annemarie M C; van Waardhuizen, Claudia N; de Wildt, Saskia N; Sweep, Boudewijn; van den Broek, Jos M; de Vries, Martine C

2017-01-01

To be able to truly involve adolescents in decision making about clinical research participation, we need more insight in the perspective of adolescents themselves. To this end, adolescents in an ongoing biobank study were consulted to test a tentative decision assessment tool. The perspectives of adolescents (n=8) concerning participation in decision making for research participation were explored in interviews with a tentative tool, which covered six topics: information material usage, understanding, disease perceptions, anxiety, decision-making process and role sharing. All adolescents unequivocally expressed the desire to be involved in decision making, but also wanted advice from their parents. The extent of the preferred role of adolescent versus parents varied between individuals. In decision making, adolescents relied on parents for information. More than half hardly used the information material. Adolescents in our study preferred a shared decision-making process. The extent of sharing varied between individuals. The decision assessment tool was a fruitful starting point to discuss adolescents' perspectives and may aid in tailoring the situation to the individual to achieve optimal participation practices. Consulting adolescents about their preferences concerning decision making using the tool will facilitate tailoring of the shared decision-making process and optimising the developing autonomy of minors.

Evaluation of a multi-arm multi-stage Bayesian design for phase II drug selection trials - an example in hemato-oncology.

PubMed

Jacob, Louis; Uvarova, Maria; Boulet, Sandrine; Begaj, Inva; Chevret, Sylvie

2016-06-02

Multi-Arm Multi-Stage designs aim at comparing several new treatments to a common reference, in order to select or drop any treatment arm to move forward when such evidence already exists based on interim analyses. We redesigned a Bayesian adaptive design initially proposed for dose-finding, focusing our interest in the comparison of multiple experimental drugs to a control on a binary criterion measure. We redesigned a phase II clinical trial that randomly allocates patients across three (one control and two experimental) treatment arms to assess dropping decision rules. We were interested in dropping any arm due to futility, either based on historical control rate (first rule) or comparison across arms (second rule), and in stopping experimental arm due to its ability to reach a sufficient response rate (third rule), using the difference of response probabilities in Bayes binomial trials between the treated and control as a measure of treatment benefit. Simulations were then conducted to investigate the decision operating characteristics under a variety of plausible scenarios, as a function of the decision thresholds. Our findings suggest that one experimental treatment was less efficient than the control and could have been dropped from the trial based on a sample of approximately 20 instead of 40 patients. In the simulation study, stopping decisions were reached sooner for the first rule than for the second rule, with close mean estimates of response rates and small bias. According to the decision threshold, the mean sample size to detect the required 0.15 absolute benefit ranged from 63 to 70 (rule 3) with false negative rates of less than 2 % (rule 1) up to 6 % (rule 2). In contrast, detecting a 0.15 inferiority in response rates required a sample size ranging on average from 23 to 35 (rules 1 and 2, respectively) with a false positive rate ranging from 3.6 to 0.6 % (rule 3). Adaptive trial design is a good way to improve clinical trials. It allows removing ineffective drugs and reducing the trial sample size, while maintaining unbiased estimates. Decision thresholds can be set according to predefined fixed error decision rates. ClinicalTrials.gov Identifier: NCT01342692 .

Attending Surgeons' Leadership Style in the Operating Room: Comparing Junior Residents' Experiences and Preferences.

PubMed

Kissane-Lee, Nicole A; Yule, Steven; Pozner, Charles N; Smink, Douglas S

2016-01-01

Recent studies have focused on surgeons' nontechnical skills in the operating room (OR), especially leadership. In an attempt to identify trainee preferences, we explored junior residents' opinions about the OR leadership style of teaching faculty. Overall, 20 interns and 20 mid-level residents completed a previously validated survey on the style of leadership they encountered, the style they preferred to receive, and the style they personally employed in the OR. In all, 4 styles were explored; authoritative: leader makes decisions and communicates them firmly; explanatory: leader makes decisions promptly, but explains them fully; consultative: leader consults with trainees when important decisions are made, and delegative: leader puts the problem before the group and makes decisions by majority opinion. Comparisons were completed using chi-square analysis. Junior resident preference for leadership style of attending surgeons in the OR differed from what they encountered. Overall, 62% of residents encountered an authoritative leadership style; however, only 9% preferred this (p < 0.001). Instead, residents preferred explanatory (53%) or consultative styles (41%). Preferences differed by postgraduate year. Although 40% of interns preferred a consultative style, 50% of mid-level residents preferred explanatory leadership. Junior resident preference of leadership style in the OR differs from what they actually encounter. This has the potential to create unwanted tension and may erode team performance. Awareness of this difference provides an opportunity for an educational intervention directed at both attendings and trainees. Copyright © 2015 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

Understanding Decision-Making, Communication Rules, and Communication Satisfaction as Culture: Implications for Organizational Effectiveness.

ERIC Educational Resources Information Center

Shockley-Zalabak, Pamela

A study of decision making processes and communication rules, in a corporate setting undergoing change as a result of organizational ineffectiveness, examined whether (1) decisions about formal communication reporting systems were linked to management assumptions about technical creativity/effectiveness, (2) assumptions about…

38 CFR 20.1401 - Rule 1401. Definitions.

Code of Federal Regulations, 2012 CFR

2012-07-01

... 38 Pensions, Bonuses, and Veterans' Relief 2 2012-07-01 2012-07-01 false Rule 1401. Definitions... Unmistakable Error § 20.1401 Rule 1401. Definitions. (a) Issue. Unless otherwise specified, the term “issue” in this subpart means a matter upon which the Board made a final decision (other than a decision under...

38 CFR 20.1401 - Rule 1401. Definitions.

Code of Federal Regulations, 2011 CFR

2011-07-01

... 38 Pensions, Bonuses, and Veterans' Relief 2 2011-07-01 2011-07-01 false Rule 1401. Definitions... Unmistakable Error § 20.1401 Rule 1401. Definitions. (a) Issue. Unless otherwise specified, the term “issue” in this subpart means a matter upon which the Board made a final decision (other than a decision under...

38 CFR 20.1401 - Rule 1401. Definitions.

Code of Federal Regulations, 2014 CFR

2014-07-01

... 38 Pensions, Bonuses, and Veterans' Relief 2 2014-07-01 2014-07-01 false Rule 1401. Definitions... Unmistakable Error § 20.1401 Rule 1401. Definitions. (a) Issue. Unless otherwise specified, the term “issue” in this subpart means a matter upon which the Board made a final decision (other than a decision under...

Respiratory therapists' attitudes about participative decision making: relationship between managerial decision-making style and job satisfaction.

PubMed

Blake, Shane S; Kester, Lucy; Stoller, James K

2004-08-01

Studies of non-health-care work environments indicate that non-managerial employee job satisfaction is higher in companies that use participative (as opposed to autocratic) decision making. It has not been determined whether managerial decision-making style influences job satisfaction among respiratory therapists (RTs) and which managerial decision-making style RTs prefer. We surveyed Nebraska RTs' attitudes regarding their job satisfaction, their perceptions of their managers' decision-making styles (autocratic, consultative, and/or delegative), and which decision-making style they would prefer their managers to use. We sought to determine whether there is a significant correlation between RTs' perceptions of their managers' decision-making styles and the RTs' job satisfaction. The study population was 792 licensed and practicing non-managerial RTs in Nebraska, from which we randomly selected 565 RTs to survey. The self-administered, descriptive survey used 2 Likert scales (one for decision-making style and one for job satisfaction) and inquired about 57 items. The survey was mailed on October 1, 1999. On October 28, 1999, we sent a second mailing to RTs who had not responded. We received 271 responses (response rate 47.9%). The respondents were generally satisfied with their jobs (mean +/- SD Minnesota Satisfaction Questionnaire score 73.46 +/- 11.63). The sub-scale scores ranged from 20 ("very dissatisfied") to 100 ("very satisfied"). The respondents did not want autocratic managerial decision making (mean +/- SD autocratic sub-scale score 4.29 +/- 0.60). Autocratic decision making was associated with lower job satisfaction (r = 0.49), whereas consultative and delegative decision making were associated with higher job satisfaction (r = -0.31 and -0.48, respectively). RTs who worked in departments that had < 25 RT employees reported higher job satisfaction than did RTs in larger departments (p = 0.029). Our survey data indicate that (1) RTs prefer delegative and consultative managerial decision making, (2) job satisfaction was highest in departments that had < 25 RTs in the department and in which the manager practiced participative decision making. These findings offer guidance for organizing optimal work environments for RTs.

Parental decision making in pediatric otoplasty: The role of shared decision making in parental decisional conflict and decisional regret.

PubMed

Hong, Paul; Gorodzinsky, Ayala Y; Taylor, Benjamin A; Chorney, Jill MacLaren

2016-07-01

To date, there has been little research on shared decision making and decisional outcomes in pediatric surgery. The objectives of this study were to describe the level of decisional conflict and decisional regret experienced by parents considering otoplasty for their children, and to determine if they are related to perceptions of shared decision making. Prospective cohort clinical study. Sixty-five consecutive parents of children who underwent surgical consultation for otoplasty were prospectively enrolled. Participants completed the Demographic Form, the Decisional Conflict Scale, and the Shared Decision-Making Questionnaire after the consultation visit. The consulting surgeons completed the physician version of the Shared Decision-Making Questionnaire. Six months after surgery, parents completed the Decisional Regret Scale. The median decisional conflict was 15.63; 21 (32.8%) parents scored 25 or above, a previously defined cutoff indicating clinically significant decisional conflict. Parent ratings of shared decision making and decisional conflict were significantly negatively correlated (P < 0.001); however, there was no significant correlation between physician ratings of shared decision making and parental decisional conflict. Significant decisional regret was reported in two (3.2%) participants. Decisional regret and parent and physician ratings of shared decision making were both significantly negatively correlated (P = 0.044 and P = 0.001, respectively). Decisional regret and decisional conflict scores were significantly positively correlated (P = 0.001). Parent and physician ratings of shared decision making were correlated (intraclass correlation = 0.625, P < 0.001). Many parents experienced significant decisional conflict when making decisions about their child's elective surgical treatment. Fewer parents experienced significant decisional regret after the procedure. Parents who perceived themselves as being more involved in the decision making process reported less decisional conflict and decisional regret. Parents and physicians had varied perceptions of the degree of shared decision making. Future research should develop interventions to increase parents' involvement in decision making and explore the influence of significant decisional conflict and decisional regret on health outcomes. 2b. Laryngoscope, 126:S5-S13, 2016. © 2016 The American Laryngological, Rhinological and Otological Society, Inc.

Design and Implementation of a Telecardiology System for Mobile Devices.

PubMed

Cinaglia, Pietro; Tradigo, Giuseppe; Guzzi, Pietro H; Veltri, Pierangelo

2015-09-01

This paper presents the design and implementation of a system for digital telecardiology on mobile devices called Remote Cardio Consultation (RCC). Using RCC may improve first intervention procedures in case of heart attack. In fact, it allows physicians to remotely consult ECG signals from a mobile device or smartphone by using a so-called app. The remote consultation is implemented by a server application collecting physician availability to answer upon client support requests. The app can be used by first intervention clinicians and allows reducing delays and decision errors in emergency interventions. Thus, best decision, certified and supported by cardiologists, can be obtained in case of heart attacks and first interventions even by base medical doctors able to produce and send an ECG. RCC tests have been performed, and the prototype is freely available as a service for testing.

Attitudes toward concordance and self-efficacy in decision making: a cross-sectional study on pharmacist-patient consultations.

PubMed

Ng, Yew Keong; Shah, Noraida Mohamed; Loong, Ly Sia; Pee, Lay Ting; Hidzir, Sarina Anim M; Chong, Wei Wen

2018-01-01

This study investigated patients' and pharmacists' attitudes toward concordance in a pharmacist-patient consultation and how patients' attitudes toward concordance relate to their involvement and self-efficacy in decision making associated with medication use. A cross-sectional study was conducted among patients with chronic diseases and pharmacists from three public hospitals in Malaysia. The Revised United States Leeds Attitudes toward Concordance (RUS-LATCon) was used to measure attitudes toward concordance in both patients and pharmacists. Patients also rated their perceived level of involvement in decision making and completed the Decision Self-Efficacy scale. One-way analysis of variance (ANOVA) and independent t -test were used to determine significant differences between different subgroups on attitudes toward concordance, and multiple linear regression was performed to find the predictors of patients' self-efficacy in decision making. A total of 389 patients and 93 pharmacists participated in the study. Pharmacists and patients scored M=3.92 (SD=0.37) and M=3.84 (SD=0.46) on the RUS-LATCon scale, respectively. Seven items were found to be significantly different between pharmacists and patients on the subscale level. Patients who felt fully involved in decision making (M=3.94, SD=0.462) scored significantly higher on attitudes toward concordance than those who felt partially involved (M=3.82, SD=0.478) and not involved at all (M=3.68, SD=0.471; p <0.001). Patients had an average score of 76.7% (SD=14.73%) on the Decision Self-Efficacy scale. In multiple linear regression analysis, ethnicity, number of medications taken by patients, patients' perceived level of involvement, and attitudes toward concordance are significant predictors of patients' self-efficacy in decision making ( p <0.05). Patients who felt involved in their consultations had more positive attitudes toward concordance and higher confidence in making an informed decision. Further study is recommended on interventions involving pharmacists in supporting patients' involvement in medication-related decision making.

How much do family physicians involve pregnant women in decisions about prenatal screening for Down syndrome?

PubMed

Gagnon, Susie; Labrecque, Michel; Njoya, Merlin; Rousseau, François; St-Jacques, Sylvie; Légaré, France

2010-02-01

To assess the extent to which family physicians (FPs) involve women in decisions about prenatal screening for Down syndrome. Based on transcripts of consultations between 41 FPs and 128 women, two raters independently assessed clinician's efforts to involve women in decisions about prenatal screening for Down syndrome using the French-language version of OPTION. Descriptive statistics of OPTION scores were calculated. Construct validity was assessed by performing a principal factor analysis and by measuring association with consultation duration and FPs sociodemograhics. Internal consistency was assessed with Cronbach's alpha and inter-rater reliability with the intraclass correlation coefficient. The overall mean OPTION score was low: 19 +/- 7 (range = 0 [no involvement] to 100 [high involvement]). One factor accounted for 80% of the variance. Both internal consistency and inter-rater reliability were very good (Cronbach's alpha = 0.73; ICC = 0.76). OPTION scores were lower for residents than for licensed FPs (17 +/- 5 vs 21 +/- 4; p = 0.02) and were positively associated with duration of consultation (r = 0.56; p < 0.001). Based on the French-language version of OPTION, which showed satisfactory psychometric properties, FPs studied put minimal efforts to involve women in decisions about prenatal screening for Down syndrome. (c) 2009 John Wiley & Sons, Ltd.

Implementation of clinical decision rules in the emergency department.

PubMed

Stiell, Ian G; Bennett, Carol

2007-11-01

Clinical decision rules (CDRs) are tools designed to help clinicians make bedside diagnostic and therapeutic decisions. The development of a CDR involves three stages: derivation, validation, and implementation. Several criteria need to be considered when designing and evaluating the results of an implementation trial. In this article, the authors review the results of implementation studies evaluating the effect of four CDRs: the Ottawa Ankle Rules, the Ottawa Knee Rule, the Canadian C-Spine Rule, and the Canadian CT Head Rule. Four implementation studies demonstrated that the implementation of CDRs in the emergency department (ED) safely reduced the use of radiography for ankle, knee, and cervical spine injuries. However, a recent trial failed to demonstrate an impact on computed tomography imaging rates. Well-developed and validated CDRs can be successfully implemented into practice, efficiently standardizing ED care. However, further research is needed to identify barriers to implementation in order to achieve improved uptake in the ED.

On implementing clinical decision support: achieving scalability and maintainability by combining business rules and ontologies.

PubMed

Kashyap, Vipul; Morales, Alfredo; Hongsermeier, Tonya

2006-01-01

We present an approach and architecture for implementing scalable and maintainable clinical decision support at the Partners HealthCare System. The architecture integrates a business rules engine that executes declarative if-then rules stored in a rule-base referencing objects and methods in a business object model. The rules engine executes object methods by invoking services implemented on the clinical data repository. Specialized inferences that support classification of data and instances into classes are identified and an approach to implement these inferences using an OWL based ontology engine is presented. Alternative representations of these specialized inferences as if-then rules or OWL axioms are explored and their impact on the scalability and maintenance of the system is presented. Architectural alternatives for integration of clinical decision support functionality with the invoking application and the underlying clinical data repository; and their associated trade-offs are discussed and presented.

Neglected ends: clinical ethics consultation and the prospects for closure.

PubMed

Fiester, Autumn

2015-01-01

Clinical ethics consultations (CECs) are sometimes deemed complete at the moment when the consultants make a recommendation. In CECs that involve actual ethical conflict, this view of a consult's endpoint runs the risk of overemphasizing the conflict's resolution at the expense of the consult's process, which can have deleterious effects on the various parties in the conflict. This overly narrow focus on reaching a decision or recommendation in consults that involve profound moral disagreement can result in two types of adverse, lingering sequelae: moral distress or negative moral emotions. The problem, succinctly named, is that such consults have insufficient "closure" for patients, families, and providers. To promote closure, and avoid the ills of moral distress and the moral emotions, I argue that CECs need to prioritize assisted conversation between the different stakeholders in these conflicts, what is often referred to as "bioethics mediation."

Clean Air Interstate Rule: Changes and Modeling in AEO2010 (released in AEO2010)

EIA Publications

2010-01-01

On December 23, 2008, the D.C. Circuit Court remanded but did not vacate the Clean Air Interstate Rule (CAIR), overriding its previous decision on February 8, 2008, to remand and vacate CAIR. The December decision, which is reflected in Annual Energy Outlook 2010 (AEO) , allows CAIR to remain in effect, providing time for the Environmental Protection Agency to modify the rule in order to address objections raised by the Court in its earlier decision. A similar rule, referred to as the Clean Air Mercury Rule (CAMR), which was to set up a cap-and-trade system for reducing mercury emissions by approximately 70%, is not represented in the AEO2010 projections, because it was vacated by the D.C. Circuit Court in February 2008.

Decision Fusion with Channel Errors in Distributed Decode-Then-Fuse Sensor Networks

PubMed Central

Yan, Yongsheng; Wang, Haiyan; Shen, Xiaohong; Zhong, Xionghu

2015-01-01

Decision fusion for distributed detection in sensor networks under non-ideal channels is investigated in this paper. Usually, the local decisions are transmitted to the fusion center (FC) and decoded, and a fusion rule is then applied to achieve a global decision. We propose an optimal likelihood ratio test (LRT)-based fusion rule to take the uncertainty of the decoded binary data due to modulation, reception mode and communication channel into account. The average bit error rate (BER) is employed to characterize such an uncertainty. Further, the detection performance is analyzed under both non-identical and identical local detection performance indices. In addition, the performance of the proposed method is compared with the existing optimal and suboptimal LRT fusion rules. The results show that the proposed fusion rule is more robust compared to these existing ones. PMID:26251908

A clinical decision rule to prioritize polysomnography in patients with suspected sleep apnea.

PubMed

Rodsutti, Julvit; Hensley, Michael; Thakkinstian, Ammarin; D'Este, Catherine; Attia, John

2004-06-15

To derive and validate a clinical decision rule that can help to prioritize patients who are on waiting lists for polysomnography, Prospective data collection on consecutive patients referred to a sleep center. The Newcastle Sleep Disorders Centre, University of Newcastle, NSW, Australia. Consecutive adult patients who had been scheduled for initial diagnostic polysomnography. Eight hundred and thirty-seven patients were used for derivation of the decision rule. An apnea-hypopnoea index of at least 5 was used as the cutoff point to diagnose sleep apnea. Fifteen clinical features were included in the analyses using logistic regression to construct a model from the derivation data set. Only 5 variables--age, sex, body mass index, snoring, and stopping breathing during sleep--were significantly associated with sleep apnea. A scoring scheme based on regression coefficients was developed, and the total score was trichotomized into low-, moderate-, and high-risk groups with prevalence of sleep apnea of 8%, 51%, and 82%, respectively. Color-coded tables were developed for ease of use. The clinical decision rule was validated on a separate set of 243 patients. Receiver operating characteristic analysis confirmed that the decision rule performed well, with the area under the curve being similar for both the derivation and validation sets: 0.81 and 0.79, P =.612. We conclude that this decision rule was able to accurately classify the risk of sleep apnea and will be useful for prioritizing patients with suspected sleep apnea who are on waiting lists for polysomnography.

18 CFR 385.2201 - Rules governing off-the-record communications (Rule 2201).

Code of Federal Regulations, 2010 CFR

2010-04-01

...) Relevant to the merits means capable of affecting the outcome of a proceeding, or of influencing a decision, or providing an opportunity to influence a decision, on any issue in the proceeding, but does not... Commission in a manner that permits fully informed decision making by the Commission while ensuring the...

18 CFR 385.704 - Rights of participants before initial decision (Rule 704).

Code of Federal Regulations, 2010 CFR

2010-04-01

... 18 Conservation of Power and Water Resources 1 2010-04-01 2010-04-01 false Rights of participants... PROCEDURE Decisions § 385.704 Rights of participants before initial decision (Rule 704). After testimony is... good cause, deny opportunity for reply or limit the issues which may be addressed in any reply. ...

17 CFR 201.410 - Appeal of initial decisions by hearing officers.

Code of Federal Regulations, 2010 CFR

2010-04-01

... COMMISSION RULES OF PRACTICE Rules of Practice Appeal to the Commission and Commission Review § 201.410 Appeal of initial decisions by hearing officers. (a) Petition for review; when available. In any... would have been entitled to judicial review of the decision entered therein if the Commission itself had...

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

PubMed

Sinopoulou, Vassiliki; Summerfield, Paul; Rutter, Paul

2017-12-01

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

Interdisciplinary Collaborative Learning: Using Decision Analysts to Enhance Undergraduate International Management Education

ERIC Educational Resources Information Center

Palocsay, Susan W.; White, Marion M.; Zimmerman, D. Kent

2004-01-01

This article describes an experiential learning activity designed to promote the development of decision-making skills in international management students at the undergraduate level. Students from an undergraduate management science course in decision analysis served as consultants on a case assigned to teams in an international management class.…

Collective intelligence meets medical decision-making: the collective outperforms the best radiologist.

PubMed

Wolf, Max; Krause, Jens; Carney, Patricia A; Bogart, Andy; Kurvers, Ralf H J M

2015-01-01

While collective intelligence (CI) is a powerful approach to increase decision accuracy, few attempts have been made to unlock its potential in medical decision-making. Here we investigated the performance of three well-known collective intelligence rules ("majority", "quorum", and "weighted quorum") when applied to mammography screening. For any particular mammogram, these rules aggregate the independent assessments of multiple radiologists into a single decision (recall the patient for additional workup or not). We found that, compared to single radiologists, any of these CI-rules both increases true positives (i.e., recalls of patients with cancer) and decreases false positives (i.e., recalls of patients without cancer), thereby overcoming one of the fundamental limitations to decision accuracy that individual radiologists face. Importantly, we find that all CI-rules systematically outperform even the best-performing individual radiologist in the respective group. Our findings demonstrate that CI can be employed to improve mammography screening; similarly, CI may have the potential to improve medical decision-making in a much wider range of contexts, including many areas of diagnostic imaging and, more generally, diagnostic decisions that are based on the subjective interpretation of evidence.

Continue, adjust, or stop antipsychotic medication: developing and user testing an encounter decision aid for people with first-episode and long-term psychosis.

PubMed

Zisman-Ilani, Yaara; Shern, David; Deegan, Patricia; Kreyenbuhl, Julie; Dixon, Lisa; Drake, Robert; Torrey, William; Mishra, Manish; Gorbenko, Ksenia; Elwyn, Glyn

2018-05-22

People with psychosis struggle with decisions about their use of antipsychotics. They often want to reduce the dose or stop, while facing uncertainty regarding the effects these decisions will have on their treatment and recovery. They may also fear raising this issue with clinicians. The purpose of this study was to develop and test a shared decision making (SDM) tool to support patients and clinicians in making decisions about antipsychotics. A diverse editorial research team developed an Encounter Decision Aid (EDA) for patients and clinicians to use as part of the psychiatric consultation. The EDA was tested using 24 semistructured interviews with participants representing six stakeholder groups: patients with first-episode psychosis, patients with long-term psychosis, family members, psychiatrists, mental health counselors, and administrators. We used inductive and deductive coding of interview transcripts to identify points to revise within three domains: general impression and purpose of the EDA; suggested changes to the content, wording, and appearance; and usability and potential contribution to the psychiatric consultation. An EDA was developed in an iterative process that yielded evidence-based answers to five frequently asked questions about antipsychotic medications. Patients with long-term psychosis and mental health counselors suggested more changes and revisions than patients with first-episode psychosis and psychiatrists. Family members suggested more revisions to the answers about potential risks of stopping or adjusting antipsychotics than other respondents. The EDA was perceived as potentially useful and feasible in psychiatric routine care, especially if presented during the consultation.

Assessing the Link between Environmental Concerns and Consumers' Decisions to Use Clean-Air Vehicles

ERIC Educational Resources Information Center

Plax, Timothy G.; Kearney, Patricia; Ross, Ted J.; Jolly, J. Christopher

2008-01-01

A consulting contract with the California Air Resources Board led to a project examining how California drivers' and fleet managers' perceptions, attitudes, and consumer behavior regarding Clean Vehicle Technologies influenced their own energy choices when it came to purchasing vehicles. The consultants examined archival research, conducted focus…

Evolving optimised decision rules for intrusion detection using particle swarm paradigm

NASA Astrophysics Data System (ADS)

Sivatha Sindhu, Siva S.; Geetha, S.; Kannan, A.

2012-12-01

The aim of this article is to construct a practical intrusion detection system (IDS) that properly analyses the statistics of network traffic pattern and classify them as normal or anomalous class. The objective of this article is to prove that the choice of effective network traffic features and a proficient machine-learning paradigm enhances the detection accuracy of IDS. In this article, a rule-based approach with a family of six decision tree classifiers, namely Decision Stump, C4.5, Naive Baye's Tree, Random Forest, Random Tree and Representative Tree model to perform the detection of anomalous network pattern is introduced. In particular, the proposed swarm optimisation-based approach selects instances that compose training set and optimised decision tree operate over this trained set producing classification rules with improved coverage, classification capability and generalisation ability. Experiment with the Knowledge Discovery and Data mining (KDD) data set which have information on traffic pattern, during normal and intrusive behaviour shows that the proposed algorithm produces optimised decision rules and outperforms other machine-learning algorithm.

Pre-implementation guidelines for infectious disease point-of-care testing in medical institutions.

PubMed

van der Eijk, Annemiek A; Tintu, Andrei N; Hays, John P

2017-01-01

Infectious disease point-of-care test (ID-POCT) devices are becoming widely available, and in this respect, international quality standards and guidelines are available for consultation once ID-POCT has been implemented into medical institutions. However, specific guidelines for consultation during the initial pre-implementation decision-making process are currently lacking. Further, there exist pre-implementation issues specific to ID-POCT. Here we present pre-implementation guidelines for consultation when considering the implementation of ID-POCT in medical institutions.

Prenatal consultation: perspectives on training, relevance, and utilization among pediatric subspecialty program directors.

PubMed

Danziger, Phoebe; Laventhal, Naomi

2018-05-08

To characterize the experience and training of house officers in prenatal consultation, and to assess program directors' perceptions regarding adequacy of training, and relevance and utilization of prenatal consultation in their field. An online survey was distributed to program directors of all ACGME-accredited programs in the United States in relevant pediatric subspecialties. Ninety-five percent (142/150) of respondents agreed that prenatal consultation from their field can impact decision-making, yet 46% (69/149) believe their prenatal consult services are underutilized. The majority (56%, 86/152) reported no formal curriculum related to prenatal consultation in their program. Nine percent (14/150) rated their trainees as not adequately trained to perform competent prenatal consultation upon graduation; 35% (52/150) rated trainees as only "somewhat" competent. Our study, the first of its kind, reveals widespread lack of formal training curricula, which may explain the finding that many graduating trainees are perceived as inadequately prepared to perform competent prenatal consultation.

The preoperative cardiology consultation: indications and risk modification.

PubMed

Groot, M W; Spronk, A; Hoeks, S E; Stolker, R J; van Lier, F

2017-11-01

The cardiologist is regularly consulted preoperatively by anaesthesiologists. However, insights into the efficiency and usefulness of these consultations are unclear. This is a retrospective study of 24,174 preoperatively screened patients ≥18 years scheduled for elective non-cardiac surgery, which resulted in 273 (1%) referrals to the cardiologist for further preoperative evaluation. Medical charts were reviewed for patient characteristics, main reason for referring, requested diagnostic tests, interventions, adjustment in medical therapy, 30-day mortality and major adverse cardiac events. The most common reason for consultation was the evaluation of a cardiac murmur (95 patients, 35%). In 167 (61%) patients, no change in therapy was initiated by the cardiologist. Six consultations (2%) led to invasive interventions (electrical cardioversion, percutaneous coronary intervention or coronary artery bypass surgery). On average, consultation delayed clearance for surgery by two weeks. In most patients referred to the cardiologist after being screened at an outpatient anaesthesiology clinic, echocardiography is performed for ruling out specific conditions and to be sure that no further improvement can be made in the patient's health. In the majority, no change in therapy was initiated by the cardiologist. A more careful consideration about the potential benefits of consulting must be made for every patient.

Effects of Expertise and Cognitive Style on Information Use in Tactical Decision Making

DTIC Science & Technology

1988-06-01

environmental situation. Demographic Characteristics Age Gender Rank/Command Level 5 Personality Characteristics Decision making style Cognitive style Learning...individuals with diverse decision making patterns to use a standard approach will adversely affect their decision making abilities. Further, the findings...Minneapolis MN: University of Minnesota, Cognitive, Science Research Group. Karp, S.A. (1963). Field dependence and overcoming embeddedness . J. Consult

American and German students' knowledge, perceptions, and behaviors with respect to over-the-counter pain relievers.

PubMed

Hanoch, Yaniv; Katsikopoulos, Konstantinos V; Gummerum, Michaela; Brass, Eric P

2007-11-01

To better understand the knowledge base and perceptions involved in the decision to buy and use over-the-counter pain relievers (OTCPRs) by taking into account the environment in which these decisions are made. The authors expected that the differences in access and marketing would affect knowledge and decision making related to OTCPRs in the United States and Germany. A survey was given to 108 undergraduate university students in the United States and Germany (58 and 50 participants, respectively). The authors found that significantly more Americans than Germans take OTCPRs and that they also take significantly more OTCPRs. Americans exhibited less knowledge about side effects than their German counterparts. When asked when they consulted package labels, Americans reported they were more likely to do so before buying a product, whereas Germans reported consulting labels before taking OTCPRs for the first time. Package labels affected more Americans' decisions to purchase OTCPRs; Americans were also less likely to consult a doctor when feeling pain but more likely to take OTCPRs. Finally, Americans viewed OTCPRs as riskier after their status changed from prescription only to over the counter, whereas Germans believed they posed less risk. This study analyzed health-related behavior by looking at how environmental factors shape decision processes related to over-the-counter drug use. The results indicate that looking at environmental factors does help to explain differences in knowledge, perceptions, and behaviors among German and American students. (PsycINFO Database Record (c) 2007 APA, all rights reserved).

Negotiating the moral order: paradoxes of ethics consultation.

PubMed

Crigger, B J

1995-06-01

Ethics consultation at the bedside has been hailed as a better way than courts and ethics committees to empower patients and make explicit the value components of treatment decisions. But close examination of the practice of ethics consultation reveals that it in fact risks subverting those ends by interpolating a third (expert) party into the doctor-patient encounter. In addition, the practice of bioethics through consultation does the broader cultural work of fashioning a shared moral order in the face of manifestly plural individual commitments. In doing so, however, bioethics furthers medicine's position as a privileged domain of public moral discourse in contemporary American society.

Rule Extracting based on MCG with its Application in Helicopter Power Train Fault Diagnosis

NASA Astrophysics Data System (ADS)

Wang, M.; Hu, N. Q.; Qin, G. J.

2011-07-01

In order to extract decision rules for fault diagnosis from incomplete historical test records for knowledge-based damage assessment of helicopter power train structure. A method that can directly extract the optimal generalized decision rules from incomplete information based on GrC was proposed. Based on semantic analysis of unknown attribute value, the granule was extended to handle incomplete information. Maximum characteristic granule (MCG) was defined based on characteristic relation, and MCG was used to construct the resolution function matrix. The optimal general decision rule was introduced, with the basic equivalent forms of propositional logic, the rules were extracted and reduction from incomplete information table. Combined with a fault diagnosis example of power train, the application approach of the method was present, and the validity of this method in knowledge acquisition was proved.

38 CFR 20.1106 - Rule 1106. Claim for death benefits by survivor-prior unfavorable decisions during veteran's...

Code of Federal Regulations, 2010 CFR

2010-07-01

... of 38 U.S.C. 6104 and 6105, issues involved in a survivor's claim for death benefits will be decided... death benefits by survivor-prior unfavorable decisions during veteran's lifetime. 20.1106 Section 20... VETERANS' APPEALS: RULES OF PRACTICE Finality § 20.1106 Rule 1106. Claim for death benefits by survivor...

48 CFR 6101.26 - Reconsideration; amendment of decisions; new hearings [Rule 26].

Code of Federal Regulations, 2012 CFR

2012-10-01

... in 6101.27(a) (Rule 27(a)) and the reasons established by the rules of common law or equity... for granting a new hearing. Upon granting a motion for a new hearing, the Board will take additional testimony and, if a decision has been issued, either amend its findings of fact and conclusions or law or...

77 FR 65137 - Consideration of Environmental Impacts of Temporary Storage of Spent Fuel After Cessation of...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-10-25

... provide input to decision-making for updating the Waste Confidence Decision and Rule and would not involve... Commission's tentative planning and decision-making schedule; g. Identify any cooperating agencies and, as... #0;notices is to give interested persons an opportunity to participate in #0;the rule making prior to...

Order of Verdict Consideration and Decision Rule Effects on Mock Jury Decision Making.

ERIC Educational Resources Information Center

Olaye, Imafidon M.

A study investigated the effects of order verdict consideration and decision rule on jury verdicts. After reading the summary of an actual trial, 240 mock jurors drawn from undergraduate communications classes were randomly assigned to six-member juries. Jury assignments were made under two verdict orders (ascending and descending order of…

Logical-Rule Models of Classification Response Times: A Synthesis of Mental-Architecture, Random-Walk, and Decision-Bound Approaches

ERIC Educational Resources Information Center

Fific, Mario; Little, Daniel R.; Nosofsky, Robert M.

2010-01-01

We formalize and provide tests of a set of logical-rule models for predicting perceptual classification response times (RTs) and choice probabilities. The models are developed by synthesizing mental-architecture, random-walk, and decision-bound approaches. According to the models, people make independent decisions about the locations of stimuli…

78 FR 19424 - Service Rules for the 698-746, 747-762 and 777-792 MHz Bands; Revision of the Commission's Rules...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-04-01

... Reconsideration (MO&O) denies or dismisses petitions seeking reconsideration of certain decisions made by the Commission in the 700 MHz Second Report and Order, relating to the 698-806 MHz Band, including decisions..., public safety narrowband relocation procedures, and the decisions not to impose wholesale requirements...

Using a patient decision aid for insulin initiation in patients with type 2 diabetes: a qualitative analysis of doctor–patient conversations in primary care consultations in Malaysia

PubMed Central

Syed, Ayeshah; Mohd Don, Zuraidah; Ng, Chirk Jenn; Lee, Yew Kong; Khoo, Ee Ming; Lee, Ping Yein; Lim Abdullah, Khatijah; Zainal, Azlin

2017-01-01

Objective To investigate whether the use of apatient decision aid (PDA) for insulin initiation fulfils its purpose of facilitating patient-centred decision-making through identifying how doctors and patients interact when using the PDA during primary care consultations. Design Conversation analysis of seven single cases of audio-recorded/video-recorded consultations between doctors and patients with type 2 diabetes, using a PDA on starting insulin. Setting Primary care in three healthcare settings: (1) one private clinic; (2) two public community clinics and (3) one primary care clinic in a public university hospital, in Negeri Sembilan and the Klang Valley in Malaysia. Participants Clinicians and seven patients with type 2 diabetes to whom insulin had been recommended. Purposive sampling was used to select a sample high in variance across healthcare settings, participant demographics and perspectives on insulin. Primary outcome measures Interaction between doctors and patients in a clinical consultation involving the use of a PDA about starting insulin. Results Doctors brought the PDA into the conversation mainly by asking information-focused ‘yes/no’ questions, and used the PDA for information exchange only if patients said they had not read it. While their contributions were limited by doctors’ questions, some patients disclosed issues or concerns. Although doctors’ PDA-related questions acted as a presequence to deliberation on starting insulin, their interactional practices raised questions on whether patients were informed and their preferences prioritised. Conclusions Interactional practices can hinder effective PDA implementation, with habits from ordinary conversation potentially influencing doctors’ practices and complicating their implementation of patient-centred decision-making. Effective interaction should therefore be emphasised in the design and delivery of PDAs and in training clinicians to use them. PMID:28490553

Shared Decision Making in Vascular Surgery: An Exploratory Study.

PubMed

Santema, T B; Stubenrouch, F E; Koelemay, M J W; Vahl, A C; Vermeulen, C F W; Visser, M J T; Ubbink, D T

2016-04-01

Shared decision making (SDM) is a process in which patients and their doctors collaborate in choosing a suitable treatment option by incorporating patient values and preferences, as well as the best available evidence. Particularly in vascular surgery, several conditions seem suitable for SDM because there are multiple treatment options. The objective of this study was to assess the degree of SDM behaviour in vascular surgery. Vascular surgeons of four Dutch hospitals selected consultations with patients who were facing a treatment decision. Immediately after the consultation, patients and surgeons completed the (subjective) SDM Q-9 and SDM Q-doc questionnaires respectively, to appreciate the perceived level of SDM behaviour. Two evaluators independently and objectively rated SDM behaviour in the audiotaped consultations, using the Observing Patient Involvement (OPTION-12) scale. Nine vascular surgeons and three vascular surgeons in training conducted 54 consultations. The patients' median SDM Q-9 score was high, 93% (IQR 79-100%), and 16/54 (29.6%) of them gave the maximum score. The surgeons' median score was also high, 84% (IQR 73-92%), while 4/54 (7.4%) gave the maximum score. In contrast, mean OPTION score was 31% (SD 11%). Surgeons hardly ever asked the patients for their preferred approach to receive information, whether they had understood the provided information, and how they would like to be involved in SDM. Currently, objective SDM behaviour among vascular surgeons is limited, even though the presented disorders allow for SDM. Hence, SDM in vascular surgical consultations could be improved by increasing the patients' and surgeons' awareness and knowledge about the concept of SDM. Copyright © 2015 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

How clinical rationing works in practice: A case study of morbid obesity surgery.

PubMed

Owen-Smith, Amanda; Donovan, Jenny; Coast, Joanna

2015-12-01

Difficulties in setting healthcare priorities are encountered throughout the world. There is no agreement on the most appropriate principles or methods for healthcare rationing although there is some consensus that it should be undertaken as systematically and accountably as possible. Although some steps towards achieving accountability have been made at the macro and meso level, at the consultation level rationing remains implicit and poorly understood. Using morbid obesity surgery as a case study, we observed a series of UK National Health Service consultations where rationing was ongoing and conducted in-depth interviews with doctors and patients (2011-2014). A longitudinal approach was taken to research and in total 22 consultations were observed and 78 interviews were undertaken. Sampling was undertaken purposively and theoretically and analyses were undertaken thematically. Clinicians needed to prioritise 55 patients from 450 eligible referrals, but disagreed over the extent to which clinical and financial factors were the driving force behind decision-making. The most prominent rationing technique observed in consultations was rationing by selection, but examples of rationing by delay, by deterrence, and by deflection were also commonplace. Although all clinicians sought to avoid rationing by denial, only six of the 22 patients recruited to the research were known to have been treated at the end of the three-year period. Most clinicians sought to manage rationing implicitly, and only one explained the link between decision-making criteria and financial constraints on care availability. Although existing frameworks for categorising NHS rationing techniques were useful in identifying implicit strategies, in practice these techniques over-lapped substantially and we have proposed a simpler framework for analysing NHS rationing decisions at the consultation level, which includes just three categories - rationing by exclusion, rationing by deterrence, and rationing by delay. Copyright © 2015. Published by Elsevier Ltd.

How can point-of-care HbA1c testing be integrated into UK primary care consultations? - A feasibility study.

PubMed

Hirst, J A; Stevens, R J; Smith, I; James, T; Gudgin, B C; Farmer, A J

2017-08-01

Point-of-care (POC) HbA1c testing gives a rapid result, allowing testing and treatment decisions to take place in a single appointment. Trials of POC testing have not been shown to improve HbA1c, possibly because of how testing was implemented. This study aimed to identify key components of POC HbA1c testing and determine strategies to optimise implementation in UK primary care. This cohort feasibility study recruited thirty patients with type 2 diabetes and HbA1c>7.5% (58mmol/mol) into three primary care clinics. Patients' clinical care included two POC HbA1c tests over six months. Data were collected on appointment duration, clinical decisions, technical performance and patient behaviour. Fifty-three POC HbA1c consultations took place during the study; clinical decisions were made in 30 consultations. Five POC consultations with a family doctor lasted on average 11min and 48 consultations with nurses took on average 24min. Five POC study visits did not take place in one clinic. POC results were uploaded to hospital records from two clinics. In total, sixty-three POC tests were performed, and there were 11 cartridge failures. No changes in HbA1c or patient behaviour were observed. HbA1c measurement with POC devices can be effectively implemented in primary care. This work has identified when these technologies might work best, as well as potential challenges. The findings can be used to inform the design of a pragmatic trial to implement POC HbA1c testing. Copyright © 2017 The Authors. Published by Elsevier B.V. All rights reserved.

From assessment to improvement of elderly care in general practice using decision support to increase adherence to ACOVE quality indicators: study protocol for randomized control trial

PubMed Central

2014-01-01

Background Previous efforts such as Assessing Care of Vulnerable Elders (ACOVE) provide quality indicators for assessing the care of elderly patients, but thus far little has been done to leverage this knowledge to improve care for these patients. We describe a clinical decision support system to improve general practitioner (GP) adherence to ACOVE quality indicators and a protocol for investigating impact on GPs’ adherence to the rules. Design We propose two randomized controlled trials among a group of Dutch GP teams on adherence to ACOVE quality indicators. In both trials a clinical decision support system provides un-intrusive feedback appearing as a color-coded, dynamically updated, list of items needing attention. The first trial pertains to real-time automatically verifiable rules. The second trial concerns non-automatically verifiable rules (adherence cannot be established by the clinical decision support system itself, but the GPs report whether they will adhere to the rules). In both trials we will randomize teams of GPs caring for the same patients into two groups, A and B. For the automatically verifiable rules, group A GPs receive support only for a specific inter-related subset of rules, and group B GPs receive support only for the remainder of the rules. For non-automatically verifiable rules, group A GPs receive feedback framed as actions with positive consequences, and group B GPs receive feedback framed as inaction with negative consequences. GPs indicate whether they adhere to non-automatically verifiable rules. In both trials, the main outcome measure is mean adherence, automatically derived or self-reported, to the rules. Discussion We relied on active end-user involvement in selecting the rules to support, and on a model for providing feedback displayed as color-coded real-time messages concerning the patient visiting the GP at that time, without interrupting the GP’s workflow with pop-ups. While these aspects are believed to increase clinical decision support system acceptance and its impact on adherence to the selected clinical rules, systems with these properties have not yet been evaluated. Trial registration Controlled Trials NTR3566 PMID:24642339

Real-time Internet connections: implications for surgical decision making in laparoscopy.

PubMed

Broderick, T J; Harnett, B M; Doarn, C R; Rodas, E B; Merrell, R C

2001-08-01

To determine whether a low-bandwidth Internet connection can provide adequate image quality to support remote real-time surgical consultation. Telemedicine has been used to support care at a distance through the use of expensive equipment and broadband communication links. In the past, the operating room has been an isolated environment that has been relatively inaccessible for real-time consultation. Recent technological advances have permitted videoconferencing over low-bandwidth, inexpensive Internet connections. If these connections are shown to provide adequate video quality for surgical applications, low-bandwidth telemedicine will open the operating room environment to remote real-time surgical consultation. Surgeons performing a laparoscopic cholecystectomy in Ecuador or the Dominican Republic shared real-time laparoscopic images with a panel of surgeons at the parent university through a dial-up Internet account. The connection permitted video and audio teleconferencing to support real-time consultation as well as the transmission of real-time images and store-and-forward images for observation by the consultant panel. A total of six live consultations were analyzed. In addition, paired local and remote images were "grabbed" from the video feed during these laparoscopic cholecystectomies. Nine of these paired images were then placed into a Web-based tool designed to evaluate the effect of transmission on image quality. The authors showed for the first time the ability to identify critical anatomic structures in laparoscopy over a low-bandwidth connection via the Internet. The consultant panel of surgeons correctly remotely identified biliary and arterial anatomy during six laparoscopic cholecystectomies. Within the Web-based questionnaire, 15 surgeons could not blindly distinguish the quality of local and remote laparoscopic images. Low-bandwidth, Internet-based telemedicine is inexpensive, effective, and almost ubiquitous. Use of these inexpensive, portable technologies will allow sharing of surgical procedures and decisions regardless of location. Internet telemedicine consistently supported real-time intraoperative consultation in laparoscopic surgery. The implications are broad with respect to quality improvement and diffusion of knowledge as well as for basic consultation.

A Hierarchical Analysis of Bridge Decision Makers ... The Role of New Technology Adoption in the Timber Bridge Market: Special Project

Treesearch

Robert L. Smith; Robert J. Bush; Daniel L. Schmoldt

1995-01-01

Bridge design engineers and local highway officials make bridge replacement decisions across the United States. The Analytical Hierarchy Process was used to characterize the bridge material selection decision of these individuals. State Department of Transportation engineers, private consulting engineers, and local highway officials were personally interviewed in...

Decisions from Experience: Why Small Samples?

ERIC Educational Resources Information Center

Hertwig, Ralph; Pleskac, Timothy J.

2010-01-01

In many decisions we cannot consult explicit statistics telling us about the risks involved in our actions. In lieu of such data, we can arrive at an understanding of our dicey options by sampling from them. The size of the samples that we take determines, ceteris paribus, how good our choices will be. Studies of decisions from experience have…

A systematic and transparent approach for assessing the methodological quality of intervention effectiveness research: the Study Design and Implementation Assessment Device (Study DIAD).

PubMed

Valentine, Jeffrey C; Cooper, Harris

2008-06-01

Assessments of studies meant to evaluate the effectiveness of interventions, programs, and policies can serve an important role in the interpretation of research results. However, evidence suggests that available quality assessment tools have poor measurement characteristics and can lead to opposing conclusions when applied to the same body of studies. These tools tend to (a) be insufficiently operational, (b) rely on arbitrary post-hoc decision rules, and (c) result in a single number to represent a multidimensional construct. In response to these limitations, a multilevel and hierarchical instrument was developed in consultation with a wide range of methodological and statistical experts. The instrument focuses on the operational details of studies and results in a profile of scores instead of a single score to represent study quality. A pilot test suggested that satisfactory between-judge agreement can be obtained using well-trained raters working in naturalistic conditions. Limitations of the instrument are discussed, but these are inherent in making decisions about study quality given incomplete reporting and in the absence of strong, contextually based information about the effects of design flaws on study outcomes. (PsycINFO Database Record (c) 2008 APA, all rights reserved).

Arriba-lib: association of an evidence-based electronic library of decision aids with communication and decision-making in patients and primary care physicians.

PubMed

Hirsch, Oliver; Keller, Heidemarie; Krones, Tanja; Donner-Banzhoff, Norbert

2012-03-01

In shared decision-making, patients are empowered to actively ask questions and participate in decisions about their healthcare based on their preferences and values. Decision aids should help patients make informed choices among diagnostic or treatment options by delivering evidence-based information on options and outcomes; however, they have rarely been field tested, especially in the primary care context. We therefore evaluated associations between the use of an interactive, transactional and evidence-based library of decision aids (arriba-lib) and communication and decision-making in patients and physicians in the primary care context. Our electronic library of decision aids ('arriba-lib') includes evidence-based modules for cardiovascular prevention, diabetes, coronary heart disease, atrial fibrillation and depression. Twenty-nine primary care physicians recruited 192 patients. We used questionnaires to ask patients and physicians about their experiences with and attitudes towards the programme. Patients were interviewed via telephone 2 months after the consultation. Data were analysed by general estimation equations, cross tab analyses and by using effect sizes. Only a minority (8.9%) of the consultations were felt to be too long because physicians said consultations were unacceptably extended by arriba-lib. We found a negative association between the detailedness of the discussion of the clinical problem's definition and the age of the patients. Physicians discuss therapeutic options in less detail with patients who have a formal education of less than 8 years. Patients who were counselled by a physician with no experience in using a decision aid more often reported that they do not remember being counselled with the help of a decision aid or do not wish to be counselled again with a decision aid. Arriba-lib has positive associations to the decision-making process in patients and physicians. It can also be used with older age groups and patients with less formal education. Physicians seem to adapt their counselling strategy to different patient groups. Prior experience with the use of decision aids has an influence on the acceptance of arriba-lib in patients but not on their decision-making or decision implementation. © 2012 The Authors. International Journal of Evidence-Based Healthcare © 2012 The Joanna Briggs Institute.

Effect of clinical decision rules, patient cost and malpractice information on clinician brain CT image ordering: a randomized controlled trial.

PubMed

Gimbel, Ronald W; Pirrallo, Ronald G; Lowe, Steven C; Wright, David W; Zhang, Lu; Woo, Min-Jae; Fontelo, Paul; Liu, Fang; Connor, Zachary

2018-03-12

The frequency of head computed tomography (CT) imaging for mild head trauma patients has raised safety and cost concerns. Validated clinical decision rules exist in the published literature and on-line sources to guide medical image ordering but are often not used by emergency department (ED) clinicians. Using simulation, we explored whether the presentation of a clinical decision rule (i.e. Canadian CT Head Rule - CCHR), findings from malpractice cases related to clinicians not ordering CT imaging in mild head trauma cases, and estimated patient out-of-pocket cost might influence clinician brain CT ordering. Understanding what type and how information may influence clinical decision making in the ordering advanced medical imaging is important in shaping the optimal design and implementation of related clinical decision support systems. Multi-center, double-blinded simulation-based randomized controlled trial. Following standardized clinical vignette presentation, clinicians made an initial imaging decision for the patient. This was followed by additional information on decision support rules, malpractice outcome review, and patient cost; each with opportunity to modify their initial order. The malpractice and cost information differed by assigned group to test the any temporal relationship. The simulation closed with a second vignette and an imaging decision. One hundred sixteen of the 167 participants (66.9%) initially ordered a brain CT scan. After CCHR presentation, the number of clinicians ordering a CT dropped to 76 (45.8%), representing a 21.1% reduction in CT ordering (P = 0.002). This reduction in CT ordering was maintained, in comparison to initial imaging orders, when presented with malpractice review information (p = 0.002) and patient cost information (p = 0.002). About 57% of clinicians changed their order during study, while 43% never modified their imaging order. This study suggests that ED clinician brain CT imaging decisions may be influenced by clinical decision support rules, patient out-of-pocket cost information and findings from malpractice case review. NCT03449862 , February 27, 2018, Retrospectively registered.

Associate editors' foreword: entrepreneurship in health education and health promotion: five cardinal rules.

PubMed

Cottrell, Randall R; Cooper, Hanna

2009-07-01

A career in health education or health promotion (HE/HP) can be developed in many ways. In past editions of this department, career development has been discussed in relation to distance (Balonna, 2001), consulting (Bookbinder, 2001), certifications (Hayden, 2005), graduate school (Cottrell & Hayden, 2007), and many other topics. This article looks at a less traditional means of career development-entrepreneurship. Health education is a field ripe with opportunities for consulting and for selling health-related products and services. Entrepreneurship can not only create financial rewards but can also provide high visibility and networking contacts that can advance one's career. This article combines both theory and practical applications to assist readers in developing entrepreneurial activities. The authors are experienced in entrepreneurial development and use that expertise to provide relevant examples and develop a framework using "five cardinal rules" for establishing an entrepreneurial enterprise in HE/HP.

Factors in Science Journal Cancellation Projects: The Roles of Faculty Consultations and Data

ERIC Educational Resources Information Center

Williamson, Jeanine; Fernandez, Peter; Dixon, Lana

2014-01-01

The economic downturn of 2007-08 forced many academic libraries in the United States to cancel journals. We surveyed life sciences librarians from ARL libraries to find out about their experiences with journal cancellations during 2008-12. Overall, we discovered that two factors were essential in decision-making: faculty consultations and data.…

Patient autonomy: a view from the kitchen.

PubMed

Struhkamp, Rita M

2005-01-01

In contemporary liberal ethics patient autonomy is often interpreted as the right to self-determination: when it comes to treatment decisions, the patient is given the right to give or withhold informed consent. This paper joins in the philosophical and ethical criticism of the liberal interpretation as it does not regard patient autonomy as a right, rule or principle, but rather as a practice. Patient autonomy, or so I will argue, is realised in the concrete activities of day-to-day health care, in the material and technological context of care, in arrangements of health care institutions, in the physical training of people with disabilities, as well as in the concrete activities of care-giving. This move from conversations in the consultation room to other sites and situations in the practice of care takes seriously the empirical reality of medical care and intends to show that patient autonomy is practically realised in a much richer and more creative way than most ethical theory seems to assume.

Rejecting the Baby Doe rules and defending a "negative" analysis of the Best Interests Standard.

PubMed

Kopelman, Loretta M

2005-08-01

Two incompatible policies exist for guiding medical decisions for extremely premature, sick, or terminally ill infants, the Best Interests Standard and the newer, 20-year old "Baby Doe" Rules. The background, including why there were two sets of Baby Doe Rules, and their differences with the Best Interests Standard, are illustrated. Two defenses of the Baby Doe Rules are considered and rejected. The first, held by Reagan, Koop, and others, is a "right-to-life" defense. The second, held by some leaders of the American Academy of Pediatrics, is that the Baby Doe Rules are benign and misunderstood. The Baby Doe Rules should be rejected since they can thwart compassionate and individualized decision-making, undercut duties to minimize unnecessary suffering, and single out one group for treatment adults would not want for themselves. In these ways, they are inferior to the older Best Interests Standard. A "negative" analysis of the Best Interests Standard is articulated and defended for decision-making for all incompetent individuals.

Age-related variance in decisions under ambiguity is explained by changes in reasoning, executive functions, and decision-making under risk.

PubMed

Schiebener, Johannes; Brand, Matthias

2017-06-01

Previous literature has explained older individuals' disadvantageous decision-making under ambiguity in the Iowa Gambling Task (IGT) by reduced emotional warning signals preceding decisions. We argue that age-related reductions in IGT performance may also be explained by reductions in certain cognitive abilities (reasoning, executive functions). In 210 participants (18-86 years), we found that the age-related variance on IGT performance occurred only in the last 60 trials. The effect was mediated by cognitive abilities and their relation with decision-making performance under risk with explicit rules (Game of Dice Task). Thus, reductions in cognitive functions in older age may be associated with both a reduced ability to gain explicit insight into the rules of the ambiguous decision situation and with failure to choose the less risky options consequently after the rules have been understood explicitly. Previous literature may have underestimated the relevance of cognitive functions for age-related decline in decision-making performance under ambiguity.

'Heads you win, tails I lose': a critical incident study of GPs' decisions about emergency admission referrals.

PubMed

Dempsey, Owen P; Bekker, Hilary L

2002-12-01

Acute hospital Trusts' inability to cope with the numbers of emergency admissions has led to the production of guidelines by the Department of Health aimed at reducing inappropriate admissions by GPs. There is a paucity of research describing GPs' decisions to (not) admit patients and it is unclear how effective these guidelines are in changing these practices. To describe GPs' decision-making about referrals for emergency hospital admissions. Observational design using the critical incident technique to elicit data. Eight GPs in West Yorkshire recorded details of memorable emergency admission decisions, both prospective and retrospective consultations. The transcript data were classified by theme using NUD*IST. Forty prospective and 8 retrospective consultations were analysed. Factors affecting GPs' decisions were:Identification of all consequences for all stakeholders in the decision. Emotional impact on the GP of managing these conflicting needs. 'Peer review' of the GP's professionalism about the decision. Contextual pressures limiting effectiveness of GPs' decision-making. Referral decisions require the evaluation of several conflicting consequences for many stakeholders in time-pressured and peer-reviewed situations. These factors encourage the use of heuristics, i.e. GPs' judgements will be influenced more by the social context of the choice than information about the patient's condition. Emergency referral guidelines provide more information to evaluate from another stakeholder; introducing guidelines is likely to increase GPs' use of heuristics and the making of less optimal decisions.

30 CFR 290.107 - Where are the rules concerning the effect of the Department not issuing a decision in my appeal...

Code of Federal Regulations, 2010 CFR

2010-07-01

... 30 Mineral Resources 2 2010-07-01 2010-07-01 false Where are the rules concerning the effect of the Department not issuing a decision in my appeal within the statutory time frame? 290.107 Section... PROCEDURES Minerals Revenue Management Appeal Procedures § 290.107 Where are the rules concerning the effect...

75 FR 19558 - Cancellation of Rule of Practice 41.200(b) Before the Board of Patent Appeals and Interferences...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-04-15

... package to OMB for its review and approval because the changes in this rule making do not affect the...: Final rule. SUMMARY: The United States Court of Appeals for the Federal Circuit issued a decision in Agilent Technologies, Inc. v. Affymetrix, Inc., 567 F.3d 1366 (Fed. Cir. 2009). That decision impacted the...

Decision aids for people facing health treatment or screening decisions.

PubMed

Stacey, Dawn; Légaré, France; Lewis, Krystina; Barry, Michael J; Bennett, Carol L; Eden, Karen B; Holmes-Rovner, Margaret; Llewellyn-Thomas, Hilary; Lyddiatt, Anne; Thomson, Richard; Trevena, Lyndal

2017-04-12

Decision aids are interventions that support patients by making their decisions explicit, providing information about options and associated benefits/harms, and helping clarify congruence between decisions and personal values. To assess the effects of decision aids in people facing treatment or screening decisions. Updated search (2012 to April 2015) in CENTRAL; MEDLINE; Embase; PsycINFO; and grey literature; includes CINAHL to September 2008. We included published randomized controlled trials comparing decision aids to usual care and/or alternative interventions. For this update, we excluded studies comparing detailed versus simple decision aids. Two reviewers independently screened citations for inclusion, extracted data, and assessed risk of bias. Primary outcomes, based on the International Patient Decision Aid Standards (IPDAS), were attributes related to the choice made and the decision-making process.Secondary outcomes were behavioural, health, and health system effects.We pooled results using mean differences (MDs) and risk ratios (RRs), applying a random-effects model. We conducted a subgroup analysis of studies that used the patient decision aid to prepare for the consultation and of those that used it in the consultation. We used GRADE to assess the strength of the evidence. We included 105 studies involving 31,043 participants. This update added 18 studies and removed 28 previously included studies comparing detailed versus simple decision aids. During the 'Risk of bias' assessment, we rated two items (selective reporting and blinding of participants/personnel) as mostly unclear due to inadequate reporting. Twelve of 105 studies were at high risk of bias.With regard to the attributes of the choice made, decision aids increased participants' knowledge (MD 13.27/100; 95% confidence interval (CI) 11.32 to 15.23; 52 studies; N = 13,316; high-quality evidence), accuracy of risk perceptions (RR 2.10; 95% CI 1.66 to 2.66; 17 studies; N = 5096; moderate-quality evidence), and congruency between informed values and care choices (RR 2.06; 95% CI 1.46 to 2.91; 10 studies; N = 4626; low-quality evidence) compared to usual care.Regarding attributes related to the decision-making process and compared to usual care, decision aids decreased decisional conflict related to feeling uninformed (MD -9.28/100; 95% CI -12.20 to -6.36; 27 studies; N = 5707; high-quality evidence), indecision about personal values (MD -8.81/100; 95% CI -11.99 to -5.63; 23 studies; N = 5068; high-quality evidence), and the proportion of people who were passive in decision making (RR 0.68; 95% CI 0.55 to 0.83; 16 studies; N = 3180; moderate-quality evidence).Decision aids reduced the proportion of undecided participants and appeared to have a positive effect on patient-clinician communication. Moreover, those exposed to a decision aid were either equally or more satisfied with their decision, the decision-making process, and/or the preparation for decision making compared to usual care.Decision aids also reduced the number of people choosing major elective invasive surgery in favour of more conservative options (RR 0.86; 95% CI 0.75 to 1.00; 18 studies; N = 3844), but this reduction reached statistical significance only after removing the study on prophylactic mastectomy for breast cancer gene carriers (RR 0.84; 95% CI 0.73 to 0.97; 17 studies; N = 3108). Compared to usual care, decision aids reduced the number of people choosing prostate-specific antigen screening (RR 0.88; 95% CI 0.80 to 0.98; 10 studies; N = 3996) and increased those choosing to start new medications for diabetes (RR 1.65; 95% CI 1.06 to 2.56; 4 studies; N = 447). For other testing and screening choices, mostly there were no differences between decision aids and usual care.The median effect of decision aids on length of consultation was 2.6 minutes longer (24 versus 21; 7.5% increase). The costs of the decision aid group were lower in two studies and similar to usual care in four studies. People receiving decision aids do not appear to differ from those receiving usual care in terms of anxiety, general health outcomes, and condition-specific health outcomes. Studies did not report adverse events associated with the use of decision aids.In subgroup analysis, we compared results for decision aids used in preparation for the consultation versus during the consultation, finding similar improvements in pooled analysis for knowledge and accurate risk perception. For other outcomes, we could not conduct formal subgroup analyses because there were too few studies in each subgroup. Compared to usual care across a wide variety of decision contexts, people exposed to decision aids feel more knowledgeable, better informed, and clearer about their values, and they probably have a more active role in decision making and more accurate risk perceptions. There is growing evidence that decision aids may improve values-congruent choices. There are no adverse effects on health outcomes or satisfaction. New for this updated is evidence indicating improved knowledge and accurate risk perceptions when decision aids are used either within or in preparation for the consultation. Further research is needed on the effects on adherence with the chosen option, cost-effectiveness, and use with lower literacy populations.

An overview of bipolar qualitative decision rules

NASA Astrophysics Data System (ADS)

Bonnefon, Jean-Francois; Dubois, Didier; Fargier, Hélène

Making a good decision is often a matter of listing and comparing positive and negative arguments, as studies in cognitive psychology have shown. In such cases, the evaluation scale should be considered bipolar, that is, negative and positive values are explicitly distinguished. Generally, positive and negative features are evaluated separately, as done in Cumulative Prospect Theory. However, contrary to the latter framework that presupposes genuine numerical assessments, decisions are often made on the basis of an ordinal ranking of the pros and the cons, and focusing on the most salient features, i.e., the decision process is qualitative. In this paper, we report on a project aiming at characterizing several decision rules, based on possibilistic order of magnitude reasoning, and tailored for the joint handling of positive and negative affects, and at testing their empirical validity. The simplest rules can be viewed as extensions of the maximin and maximax criteria to the bipolar case and, like them, suffer from a lack of discrimination power. More decisive rules that refine them are also proposed. They account for both the principle of Pareto-efficiency and the notion of order of magnitude reasoning. The most decisive one uses a lexicographic ranking of the pros and cons. It comes down to a special case of Cumulative Prospect Theory, and subsumes the “Take the best” heuristic.

78 FR 5213 - Self-Regulatory Organizations; New York Stock Exchange LLC; Notice of Filing of Proposed Rule...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-01-24

... which is delegated the authority to review disciplinary decisions on behalf of the Exchange Board of... organization. Under the rule, the decision of a majority of the Hearing Panel is the decision of the Hearing..., may request a determination of guilt by default, and may recommend a penalty to be imposed. If the...

75 FR 39715 - Self-Regulatory Organizations; Financial Industry Regulatory Authority, Inc.; Notice of Filing of...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-07-12

... that a refusal by a member to take action necessary to effectuate a final decision of a FINRA officer... necessary to effectuate a final decision of a FINRA officer or the UPC Committee under the UPC Code (FINRA Rule 11000 Series) or other FINRA rules that permit review of FINRA decisions by the UPC Committee...

48 CFR 6101.26 - Reconsideration; amendment of decisions; new hearings [Rule 26].

Code of Federal Regulations, 2010 CFR

2010-10-01

... amend a decision or order for any reason that would justify such action on motion of a party. (d) Effect... for granting a new hearing. Upon granting a motion for a new hearing, the Board will take additional... issue a new decision. (b) Procedure. Any motion under 6101.26 (Rule 26) shall comply with the provisions...

48 CFR 6101.26 - Reconsideration; amendment of decisions; new hearings [Rule 26].

Code of Federal Regulations, 2011 CFR

2011-10-01

... amend a decision or order for any reason that would justify such action on motion of a party. (d) Effect... for granting a new hearing. Upon granting a motion for a new hearing, the Board will take additional... issue a new decision. (b) Procedure. Any motion under 6101.26 (Rule 26) shall comply with the provisions...

An Autonomous Flight Safety System

DTIC Science & Technology

2008-11-01

are taken. AFSS can take vehicle navigation data from redundant onboard sensors and make flight termination decisions using software-based rules...implemented on redundant flight processors. By basing these decisions on actual Instantaneous Impact Predictions and by providing for an arbitrary...number of mission rules, it is the contention of the AFSS development team that the decision making process used by Missile Flight Control Officers

Learning together for effective collaboration in school-based occupational therapy practice.

PubMed

Villeneuve, Michelle A; Shulha, Lyn M

2012-12-01

School-based occupational therapy (SBOT) practice takes place within a complex system that includes service recipients, service providers, and program decision makers across health and education sectors. Despite the promotion of collaborative consultation at a policy level, there is little practical guidance about how to coordinate multi-agency service and interprofessional collaboration among these stakeholders. This paper reports on a process used to engage program administrators in an examination of SBOT collaborative consultation practice in one region of Ontario to provide an evidence-informed foundation for decision making about implementation of these services. Within an appreciative inquiry framework (Cooperrider, Whitney, & Stavros, 2008), Developmental Work Research methods (Engeström, 2000) were used to facilitate shared learning for improved SBOT collaborative consultation. Program administrators participated alongside program providers and service recipients in a series of facilitated workshops to develop principles that will guide future planning and decision making about the delivery of SBOT services. Facilitated discussion among stakeholders led to the articulation of 12 principles for effective collaborative practice. Program administrators used their shared understanding to propose a new model for delivering SBOT services. Horizontal and vertical learning across agency and professional boundaries led to the development of powerful solutions for program improvement.

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

PubMed

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

2017-04-05

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

Acceptability and Perceived Benefits and Risks of Public and Patient Involvement in Health Care Policy: A Delphi Survey in Belgian Stakeholders.

PubMed

Cleemput, Irina; Christiaens, Wendy; Kohn, Laurence; Léonard, Christian; Daue, François; Denis, Alain

2015-06-01

In systems with public health insurance, coverage decisions should reflect social values. Deliberation among stakeholders could achieve this goal, but rarely involves patients and citizens directly. This study aimed at evaluating the acceptability, and the perceived benefits and risks, of public and patient involvement (PPI) in coverage decision making to Belgian stakeholders. A two-round Delphi survey was conducted among all stakeholder groups. The survey was constructed on the basis of interviews with 10 key stakeholders and a review of the literature on participation models. Consensus was defined as 65% or more of the respondents agreeing with a statement and less than 15% disagreeing. Eighty stakeholders participated in both rounds. They were defined as the Delphi panel. Belgian stakeholders are open toward PPI in coverage decision processes. Benefits are expected to exceed risks. The preferred model for involvement is to consult citizens or patients, within the existing decision-making structures and at specific milestones in the process. Consulting citizens and patients is a higher level of involvement than merely informing them and a lower level than letting them participate actively. Consultation involves asking nonbinding advice on (parts of) the decision problem. According to the Delphi panel, the benefits of PPI could be increasing awareness among members of the general public and patients about the challenges and costs of health care, and enriched decision processes with expertise by experience from patients. Potential risks include subjectivity, insufficient resources to participate and weigh on the process, difficulties in finding effective ways to express a collective opinion, the risk of manipulation, and lobbying or power games of other stakeholders. PPI in coverage decision-making processes is acceptable to Belgian stakeholders, be it in different ways for different types of decisions. Benefits are expected to outweigh risks. Copyright © 2015 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved.

Determining rules for closing customer service centers: A public utility company's fuzzy decision

NASA Technical Reports Server (NTRS)

Dekorvin, Andre; Shipley, Margaret F.; Lea, Robert N.

1992-01-01

In the present work, we consider the general problem of knowledge acquisition under uncertainty. Simply stated, the problem reduces to the following: how can we capture the knowledge of an expert when the expert is unable to clearly formulate how he or she arrives at a decision? A commonly used method is to learn by examples. We observe how the expert solves specific cases and from this infer some rules by which the decision may have been made. Unique to our work is the fuzzy set representation of the conditions or attributes upon which the expert may possibly base his fuzzy decision. From our examples, we infer certain and possible fuzzy rules for closing a customer service center and illustrate the importance of having the decision closely relate to the conditions under consideration.

Use of evidence-based management in healthcare administration decision-making.

PubMed

Guo, Ruiling; Berkshire, Steven D; Fulton, Lawrence V; Hermanson, Patrick M

2017-07-03

Purpose The purpose of this paper is to examine whether healthcare leaders use evidence-based management (EBMgt) when facing major decisions and what types of evidence healthcare administrators consult during their decision-making. This study also intends to identify any relationship that might exist among adoption of EBMgt in healthcare management, attitudes towards EBMgt, demographic characteristics and organizational characteristics. Design/methodology/approach A cross-sectional study was conducted among US healthcare leaders. Spearman's correlation and logistic regression were performed using the Statistical Package for the Social Sciences (SPSS) 23.0. Findings One hundred and fifty-four healthcare leaders completed the survey. The study results indicated that 90 per cent of the participants self-reported having used an EBMgt approach for decision-making. Professional experiences (87 per cent), organizational data (84 per cent) and stakeholders' values (63 per cent) were the top three types of evidence consulted daily and weekly for decision-making. Case study (75 per cent) and scientific research findings (75 per cent) were the top two types of evidence consulted monthly or less than once a month. An exploratory, stepwise logistic regression model correctly classified 75.3 per cent of all observations for a dichotomous "use of EBMgt" response variable using three independent variables: attitude towards EBMgt, number of employees in the organization and the job position. Spearman's correlation indicated statistically significant relationships between healthcare leaders' use of EBMgt and healthcare organization bed size ( r s = 0.217, n = 152, p < 0.01), attitude towards EBMgt ( r s = 0.517, n = 152, p < 0.01), and the number of organization employees ( r s = 0.195, n = 152, p = 0.016). Originality/value This study generated new research findings on the practice of EBMgt in US healthcare administration decision-making.

78 FR 36434 - Revisions to Rules of Practice

Federal Register 2010, 2011, 2012, 2013, 2014

2013-06-18

... federal holidays, make grammatical corrections, and remove the reference to part-day holidays. Rule 3001... section, the following categories of persons are designated ``decision-making personnel'': (i) The.... The following categories of person are designated ``non-decision-making personnel'': (i) All...

Extracting decision rules from police accident reports through decision trees.

PubMed

de Oña, Juan; López, Griselda; Abellán, Joaquín

2013-01-01

Given the current number of road accidents, the aim of many road safety analysts is to identify the main factors that contribute to crash severity. To pinpoint those factors, this paper shows an application that applies some of the methods most commonly used to build decision trees (DTs), which have not been applied to the road safety field before. An analysis of accidents on rural highways in the province of Granada (Spain) between 2003 and 2009 (both inclusive) showed that the methods used to build DTs serve our purpose and may even be complementary. Applying these methods has enabled potentially useful decision rules to be extracted that could be used by road safety analysts. For instance, some of the rules may indicate that women, contrary to men, increase their risk of severity under bad lighting conditions. The rules could be used in road safety campaigns to mitigate specific problems. This would enable managers to implement priority actions based on a classification of accidents by types (depending on their severity). However, the primary importance of this proposal is that other databases not used here (i.e. other infrastructure, roads and countries) could be used to identify unconventional problems in a manner easy for road safety managers to understand, as decision rules. Copyright © 2012 Elsevier Ltd. All rights reserved.

Form and Objective of the Decision Rule in Absolute Identification

NASA Technical Reports Server (NTRS)

Balakrishnan, J. D.

1997-01-01

In several conditions of a line length identification experiment, the subjects' decision making strategies were systematically biased against the responses on the edges of the stimulus range. When the range and number of the stimuli were small, the bias caused the percentage of correct responses to be highest in the center and lowest on the extremes of the range. Two general classes of decision rules that would explain these results are considered. The first class assumes that subjects intend to adopt an optimal decision rule, but systematically misrepresent one or more parameters of the decision making context. The second class assumes that subjects use a different measure of performance than the one assumed by the experimenter: instead of maximizing the chances of a correct response, the subject attempts to minimize the expected size of the response error (a "fidelity criterion"). In a second experiment, extended experience and feedback did not diminish the bias effect, but explicitly penalizing all response errors equally, regardless of their size, did reduce or eliminate it in some subjects. Both results favor the fidelity criterion over the optimal rule.

Factors influencing common diagnoses made during first-opinion small-animal consultations in the United Kingdom.

PubMed

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

2016-09-01

It is currently unclear how frequently a diagnosis is made during small-animal consultations or how much of a role making a diagnosis plays in veterinary decision-making. Understanding more about the diagnostic process will help direct future research towards areas relevant to practicing veterinary surgeons. The aim of this study was to determine the frequency with which a diagnosis was made, classify the types of diagnosis made (and the factors influencing these) and determine which specific diagnoses were made for health problems discussed during small-animal consultations. Data were gathered during real-time direct observation of small-animal consultations in eight practices in the United Kingdom. Data collected included characteristics of the consultation (e.g. consultation type), patient (e.g. breed), and each problem discussed (e.g. new or pre-existing problem). Each problem discussed was classified into one of the following diagnosis types: definitive; working; presumed; open; previous. A three-level multivariable logistic-regression model was developed, with problem (Level 1) nested within patient (Level 2) nested within consulting veterinary surgeon (Level 3). Problems without a previous diagnosis, in cats and dogs only, were included in the model, which had a binary outcome variable of definitive diagnosis versus no definitive diagnosis. Data were recorded for 1901 animals presented, and data on diagnosis were gathered for 3192 health problems. Previous diagnoses were the most common diagnosis type (n=1116/3192; 35.0%), followed by open (n=868/3192; 27.2%) then definitive (n=660/3192; 20.7%). The variables remaining in the final model were patient age, problem history, consultation type, who raised the problem, and body system affected. New problems, problems in younger animals, and problems raised by the veterinary surgeon were more likely to result in a definitive diagnosis than pre-existing problems, problems in older animals, and problems raised by the owner. The most common diagnoses made were overweight/obese and periodontal disease (both n=210; 6.6%). Definitive diagnoses are rarely made during small-animal consultations, with much of the veterinary caseload involving management of ongoing problems or making decisions around new problems prior to a diagnosis being made. This needs to be taken into account when considering future research priorities, and it may be necessary to conduct research focused on the approach to common clinical presentations, rather than purely on the common diagnoses made. Examining how making a diagnosis affects the actions taken during the consultation may shed further light on the role of diagnosis in the clinical decision-making process. Copyright © 2016 The Authors. Published by Elsevier B.V. All rights reserved.

"If it's worth my time, i will make the time": school-based providers' decision-making about participating in an evidence-based psychotherapy consultation program.

PubMed

Lyon, Aaron R; Ludwig, Kristy; Romano, Evalynn; Leonard, Skyler; Stoep, Ann Vander; McCauley, Elizabeth

2013-11-01

This study evaluated influences on school-based clinicians' decision-making surrounding participation in a modular psychotherapy training and consultation program lasting one academic year. Clinicians were recruited from three participation groups: those who never engaged, those who engaged and then discontinued, and those who participated fully. Qualitative interviews explored influences on initial and continued participation, as well as differences in decision-making by participation group, knowledge about evidence-based practices, and attitudes toward evidence-based practices. Eight major themes were identified: time, practice utility, intervention/training content, training process, attitudes toward training, social influences, commitment to training, and expectations. Some themes were discussed universally across all comparison groups, while others varied in frequency or content. Recommendations for increasing participation are presented, based on the findings.

Scientific decision-making and stakeholder consultations: the case of salt recommendations.

PubMed

Timotijevic, Lada; Barnett, Julie; Brown, Kerry; Raats, Monique M; Shepherd, Richard

2013-05-01

Scientific advisory committees (SACs) are seen as "boundary organisations" working at the interface between science, policy and society. Although their narrowly defined remit of risk assessment is anchored in notions of rationality, objectivity, and reason, in reality, their sources for developing recommendations are not limited to scientific evidence. There is a growing expectation to involve non-scientific sources of information in the formation of knowledge, including the expectation of stakeholder consultation in forming recommendations. Such a move towards "democratisation" of scientific processes of decision-making within SACs has been described and often studied as "post-normal science" (PNS) (Funtowicz & Ravetz, 1993). In the current paper we examine the application of PNS in practice through a study of stakeholder consultations within the workings of the UK Scientific Advisory Committee for Nutrition (SACN). We use the theoretical insights from PNS-related studies to structure the analysis and examine the way in which PNS tenets resonate with the practices of SACN. We have selected a particular case of the SACN UK recommendations for salt as it is characterized by scientific controversy, uncertainty, vested interests and value conflict. We apply the tenets of PNS through documentary analysis of the SACN Salt Subgroup (SSG) consultation documents published in 2002/2003: the minutes of the 5 SACN SSG's meetings which included summary of the SACN SSG's stakeholder consultation and the SSG's responses to the consultation. The analysis suggests that the SACN consultation can be construed as a process of managing sources of risk to its organisation. Thus, rather than being an evidence of post-normal scientific practice, engagement became a mechanism for confirming the specific framing of science that is resonant with technocratic models of science holding authority over the facts. The implications for PNS theory are discussed. Copyright © 2013 Elsevier Ltd. All rights reserved.

A Bayesian model averaging method for the derivation of reservoir operating rules

NASA Astrophysics Data System (ADS)

Zhang, Jingwen; Liu, Pan; Wang, Hao; Lei, Xiaohui; Zhou, Yanlai

2015-09-01

Because the intrinsic dynamics among optimal decision making, inflow processes and reservoir characteristics are complex, functional forms of reservoir operating rules are always determined subjectively. As a result, the uncertainty of selecting form and/or model involved in reservoir operating rules must be analyzed and evaluated. In this study, we analyze the uncertainty of reservoir operating rules using the Bayesian model averaging (BMA) model. Three popular operating rules, namely piecewise linear regression, surface fitting and a least-squares support vector machine, are established based on the optimal deterministic reservoir operation. These individual models provide three-member decisions for the BMA combination, enabling the 90% release interval to be estimated by the Markov Chain Monte Carlo simulation. A case study of China's the Baise reservoir shows that: (1) the optimal deterministic reservoir operation, superior to any reservoir operating rules, is used as the samples to derive the rules; (2) the least-squares support vector machine model is more effective than both piecewise linear regression and surface fitting; (3) BMA outperforms any individual model of operating rules based on the optimal trajectories. It is revealed that the proposed model can reduce the uncertainty of operating rules, which is of great potential benefit in evaluating the confidence interval of decisions.

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

PubMed Central

2012-01-01

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

Intermodal Ground Access to Airports: A Planning Guide - A Good Start

DOT National Transportation Integrated Search

1997-01-01

This Guide is designed to provide policy guidance, rules of thumb, data, and analytical techniques related to airport access. It has been prepared to help airport operator, local governments, metropolitan planning organizations, consultants and other...

How accurate are interpretations of curriculum-based measurement progress monitoring data? Visual analysis versus decision rules.

PubMed

Van Norman, Ethan R; Christ, Theodore J

2016-10-01

Curriculum based measurement of oral reading (CBM-R) is used to monitor the effects of academic interventions for individual students. Decisions to continue, modify, or terminate these interventions are made by interpreting time series CBM-R data. Such interpretation is founded upon visual analysis or the application of decision rules. The purpose of this study was to compare the accuracy of visual analysis and decision rules. Visual analysts interpreted 108 CBM-R progress monitoring graphs one of three ways: (a) without graphic aids, (b) with a goal line, or (c) with a goal line and a trend line. Graphs differed along three dimensions, including trend magnitude, variability of observations, and duration of data collection. Automated trend line and data point decision rules were also applied to each graph. Inferential analyses permitted the estimation of the probability of a correct decision (i.e., the student is improving - continue the intervention, or the student is not improving - discontinue the intervention) for each evaluation method as a function of trend magnitude, variability of observations, and duration of data collection. All evaluation methods performed better when students made adequate progress. Visual analysis and decision rules performed similarly when observations were less variable. Results suggest that educators should collect data for more than six weeks, take steps to control measurement error, and visually analyze graphs when data are variable. Implications for practice and research are discussed. Copyright © 2016 Society for the Study of School Psychology. Published by Elsevier Ltd. All rights reserved.

Ethics consultation and autonomy.

PubMed

Varelius, Jukka

2008-03-01

Services of ethics consultants are nowadays commonly used in such various spheres of life as engineering, public administration, business, law, health care, journalism, and scientific research. It has however been maintained that use of ethics consultants is incompatible with personal autonomy; in moral matters individuals should be allowed to make their own decisions. The problem this criticism refers to can be conceived of as a conflict between the professional autonomy of ethics experts and the autonomy of the persons they serve. This paper addresses this conflict and maintains that when the nature of both ethics consultation and individual autonomy is properly understood, the professional autonomy of ethics experts is compatible with the autonomy of the persons they assist.

40 CFR 25.4 - Information, notification, and consultation responsibilities.

Code of Federal Regulations, 2013 CFR

2013-07-01

..., consistent with applicable statutory requirements, the social, economic, and environmental consequences of... complex technical materials that relate to significant decisions should be summarized for public and media... media in advance of times at which major decisions not covered by notice requirements for public...

40 CFR 25.4 - Information, notification, and consultation responsibilities.

Code of Federal Regulations, 2011 CFR

2011-07-01

..., consistent with applicable statutory requirements, the social, economic, and environmental consequences of... complex technical materials that relate to significant decisions should be summarized for public and media... media in advance of times at which major decisions not covered by notice requirements for public...

40 CFR 25.4 - Information, notification, and consultation responsibilities.

Code of Federal Regulations, 2012 CFR

2012-07-01

..., consistent with applicable statutory requirements, the social, economic, and environmental consequences of... complex technical materials that relate to significant decisions should be summarized for public and media... media in advance of times at which major decisions not covered by notice requirements for public...

40 CFR 25.4 - Information, notification, and consultation responsibilities.

Code of Federal Regulations, 2014 CFR

2014-07-01

..., consistent with applicable statutory requirements, the social, economic, and environmental consequences of... complex technical materials that relate to significant decisions should be summarized for public and media... media in advance of times at which major decisions not covered by notice requirements for public...

40 CFR 25.4 - Information, notification, and consultation responsibilities.

Code of Federal Regulations, 2010 CFR

2010-07-01

..., consistent with applicable statutory requirements, the social, economic, and environmental consequences of... complex technical materials that relate to significant decisions should be summarized for public and media... media in advance of times at which major decisions not covered by notice requirements for public...

Attitudes toward concordance and self-efficacy in decision making: a cross-sectional study on pharmacist–patient consultations

PubMed Central

Ng, Yew Keong; Shah, Noraida Mohamed; Loong, Ly Sia; Pee, Lay Ting; Hidzir, Sarina Anim M; Chong, Wei Wen

2018-01-01

Purpose This study investigated patients’ and pharmacists’ attitudes toward concordance in a pharmacist–patient consultation and how patients’ attitudes toward concordance relate to their involvement and self-efficacy in decision making associated with medication use. Subjects and methods A cross-sectional study was conducted among patients with chronic diseases and pharmacists from three public hospitals in Malaysia. The Revised United States Leeds Attitudes toward Concordance (RUS-LATCon) was used to measure attitudes toward concordance in both patients and pharmacists. Patients also rated their perceived level of involvement in decision making and completed the Decision Self-Efficacy scale. One-way analysis of variance (ANOVA) and independent t-test were used to determine significant differences between different subgroups on attitudes toward concordance, and multiple linear regression was performed to find the predictors of patients’ self-efficacy in decision making. Results A total of 389 patients and 93 pharmacists participated in the study. Pharmacists and patients scored M=3.92 (SD=0.37) and M=3.84 (SD=0.46) on the RUS-LATCon scale, respectively. Seven items were found to be significantly different between pharmacists and patients on the subscale level. Patients who felt fully involved in decision making (M=3.94, SD=0.462) scored significantly higher on attitudes toward concordance than those who felt partially involved (M=3.82, SD=0.478) and not involved at all (M=3.68, SD=0.471; p<0.001). Patients had an average score of 76.7% (SD=14.73%) on the Decision Self-Efficacy scale. In multiple linear regression analysis, ethnicity, number of medications taken by patients, patients’ perceived level of involvement, and attitudes toward concordance are significant predictors of patients’ self-efficacy in decision making (p<0.05). Conclusion Patients who felt involved in their consultations had more positive attitudes toward concordance and higher confidence in making an informed decision. Further study is recommended on interventions involving pharmacists in supporting patients’ involvement in medication-related decision making. PMID:29731609

Managing resources in NHS dentistry: the views of decision-makers in primary care organisations.

PubMed

Holmes, R D; Donaldson, C; Exley, C; Steele, J G

2008-09-27

To investigate priority setting and decision-making in primary care organisations and to determine how resources are managed in order to meet the oral health needs of local populations. This is a qualitative study. The purposive sample comprised twelve dental public health consultants and six senior finance representatives from contrasting care systems across the United Kingdom. Participants completed a written information sheet followed by a recorded semi-structured telephone interview. Conversations were professionally transcribed verbatim and analysed independently by two investigators using the constant comparative method. The emergent themes focused upon: the role of participants in decision-making; professional relationships; managing change; information needs; and identifying and managing priorities. There was wide interpretation with respect to participants' roles and perceived information needs for decision-making and commissioning. A unifying factor was the importance placed by participants upon trust and the influence of individuals on the success of relationships forged between primary care organisations and general dental practitioners. To facilitate decision-making in primary care organisations, commissioners and managers could engage further with practitioners and incorporate them into commissioning and resource allocation processes. Greater clarity is required regarding the role of dental public health consultants within primary care organisations and commissioning decisions.

Rules of thumb for superfund remedy selection

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

NONE

1997-08-01

The guidance document describes key principles and expectations, interspersed with `best practices` based on program experience, that should be consulted during the Superfund remedy selection process. These remedy selection `Rules of Thumb` are organized into three major policy areas: (1) risk assessment and risk management, (2) developing remedial alternatives, and (3) ground-water response actions. The purpose of this guide is to briefly summarize key elements of various remedy selection guidance documents and policies in one publication.

Application of decision rules for empowering of Indonesian telematics services SMEs

NASA Astrophysics Data System (ADS)

Tosida, E. T.; Hairlangga, O.; Amirudin, F.; Ridwanah, M.

2018-03-01

The independence of the field of telematics became one of Indonesia's vision in 2024. One effort to achieve it can be done by empowering SMEs in the field of telematics. Empowerment carried out need a practical mechanism by utilizing data centered, including through the National Economic Census database (Susenas). Based on the Susenas can be formulated the decision rules of determining the provision of assistance for SMEs in the field of telematics. The way it did by generating the rule base through the classification technique. The CART algorithm-based decision rule model performs better than C45 and ID3 models. The high level of performance model is also in line with the regulations applied by the government. This becomes one of the strengths of research, because the resulting model is consistent with the existing conditions in Indonesia. The rules base generated from the three classification techniques show different rules. The CART technique has pattern matching with the realization of activities in The Ministry of Cooperatives and SMEs. So far, the government has difficulty in referring data related to the empowerment of SMEs telematics services. Therefore, the findings resulting from this research can be used as an alternative decision support system related to the program of empowerment of SMEs in telematics.

Nationwide survey to evaluate the decision-making process in euthanasia requests in Belgium: do specifically trained 2nd physicians improve quality of consultation?

PubMed

Cohen, Joachim; Van Wesemael, Yanna; Smets, Tinne; Bilsen, Johan; Onwuteaka-Philipsen, Bregje; Distelmans, Wim; Deliens, Luc

2014-07-16

Following the 2002 enactment of the Belgian law on euthanasia, which requires the consultation of an independent second physician before proceeding with euthanasia, the Life End Information Forum (LEIF) was founded which provides specifically trained physicians who can act as mandatory consultants in euthanasia requests. This study assesses quality of consultations in Flanders and Brussels and compares these between LEIF and non-LEIF consultants. A questionnaire was sent in 2009 to a random sample of 3,006 physicians in Belgium from specialties likely involved in the care of dying patients. Several questions about the last euthanasia request of one of their patients were asked. As LEIF serves the Flemish speaking community (i.e. region of Flanders and the bilingual Brussels Capital Region) and no similar counterpart is present in Wallonia, analyses were limited to Flemish speaking physicians in Flanders and Brussels. Response was 34%. Of the 244 physicians who indicated having received a euthanasia request seventy percent consulted a second physician in their last request; in 30% this was with a LEIF physician. Compared to non-LEIF physicians, LEIF physicians were more often not a colleague (69% vs 42%) and not a co-attending physician (89% vs 66%). They tended to more often discuss the request with the attending physician (100% vs 95%) and with the family (76% vs 69%), and also more frequently helped the attending physician with performing euthanasia (44% vs 24%). No significant differences were found in the extent to which they talked to the patient (96% vs 93%) and examined the patient file (94% vs 97%). In cases of explicit euthanasia requests in Belgium, the consultation procedure of another physician by the attending physician is not optimal and can be improved. Training and putting at disposal consultants through forums such as LEIF seems able to improve this situation. Adding stipulations in the law about the necessary competencies and tasks of consulting physicians may additionally incite improvement. Irrespective of whether euthanasia is a legal practice within a country, similar services may prove useful to also improve quality of consultations in various other difficult end-of-life decision-making situations.

Medicare Program; Prior Authorization Process for Certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies. Final rule.

PubMed

2015-12-30

This final rule establishes a prior authorization program for certain durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) items that are frequently subject to unnecessary utilization. This rule defines unnecessary utilization and creates a new requirement that claims for certain DMEPOS items must have an associated provisional affirmed prior authorization decision as a condition of payment. This rule also adds the review contractor's decision regarding prior authorization of coverage of DMEPOS items to the list of actions that are not initial determinations and therefore not appealable.

Shared decision making: what do clinicians need to know and why should they bother?

PubMed

Hoffmann, Tammy C; Légaré, France; Simmons, Magenta B; McNamara, Kevin; McCaffery, Kirsten; Trevena, Lyndal J; Hudson, Ben; Glasziou, Paul P; Del Mar, Christopher B

2014-07-07

Shared decision making enables a clinician and patient to participate jointly in making a health decision, having discussed the options and their benefits and harms, and having considered the patient's values, preferences and circumstances. It is not a single step to be added into a consultation, but a process that can be used to guide decisions about screening, investigations and treatments. The benefits of shared decision making include enabling evidence and patients' preferences to be incorporated into a consultation; improving patient knowledge, risk perception accuracy and patient-clinician communication; and reducing decisional conflict, feeling uninformed and inappropriate use of tests and treatments. Various approaches can be used to guide clinicians through the process. We elaborate on five simple questions that can be used: What will happen if the patient waits and watches? What are the test or treatment options? What are the benefits and harms of each option? How do the benefits and harms weigh up for the patient? Does the patient have enough information to make a choice? Although shared decision making can occur without tools, various types of decision support tools now exist to facilitate it. Misconceptions about shared decision making are hampering its implementation. We address the barriers, as perceived by clinicians. Despite numerous international initiatives to advance shared decision making, very little has occurred in Australia. Consequently, we are lagging behind many other countries and should act urgently.

Adaptation of a Knowledge-Based Decision-Support System in the Tactical Environment.

DTIC Science & Technology

1981-12-01

002-04-6411S1CURITY CL All PICATION OF 1,416 PAGE (00HIR Onto ea0aOW .L10 *GU9WVC 4bGSI.CAYON S. Voss 10466lVka t... OftesoE ’ making decisons . The...noe..aaw Ad tdlalttt’ IV 680011 MMib) Artificial Intelligence; Decision-Support Systems; Tactical Decision- making ; Knowledge-based Decision-support...tactical information to assist tactical commanders in making decisions. The system, TAC*, for "Tactical Adaptable Consultant," incorporates a database

Do Consultation Psychiatrists, Forensic Psychiatrists, Psychiatry Trainees, and Health Care Lawyers Differ in Opinion on Gray Area Decision-Making Capacity Cases? A Vignette-Based Survey.

PubMed

Armontrout, James; Gitlin, David; Gutheil, Thomas

2016-01-01

Previous research in the area of medical decision-making capacity has demonstrated relatively poor agreement between experienced evaluators in "gray area" cases. We performed a survey to determine the level of agreement about gray area decision-making capacity case scenarios within and between individuals of different professional backgrounds. Participants received a survey consisting of 3 complicated decision-making capacity vignettes with an accompanying "yes/no" question regarding capacity and a certainty scale for each vignette. Participants were identified from mailing lists of professional organizations and local hospitals. We received responses from psychiatry trainees, consultation-liaison psychiatrists, forensic psychiatrists, and lawyers with experience in health care law. Results were analyzed using SPSS. Across the 3 vignettes, the percentage agreeing that the individual described had capacity to refuse medical treatment ranged between 35% and 40% for trainees, 33% and 67% for consult psychiatrists, 41% and 76% for forensic psychiatrists, and 40% and 83% for health care lawyers. Only question 2 reached significance between-group differences (Pearson χ(2) = 11.473, p < 0.01). Across vignettes, trainees were less likely to consider patients to have capacity for decision-making than were forensic psychiatrists and lawyers. As found in previous research, agreement among experienced evaluators appears generally low in gray area capacity cases. It is noteworthy that individuals of different professional backgrounds at times offer divergent between-group opinions on capacity. Copyright © 2016 The Academy of Psychosomatic Medicine. Published by Elsevier Inc. All rights reserved.

Identifying Training Needs to Improve Indigenous Community Representatives Input into Environmental Resource Management Consultative Processes: A Case Study of the Bundjalung Nation

ERIC Educational Resources Information Center

Lloyd, David; Norrie, Fiona

2004-01-01

Despite increased engagement of Indigenous representatives as participants on consultative panels charged with processes of natural resource management, concerns have been raised by both Indigenous representatives and management agencies regarding the ability of Indigenous people to have quality input into the decisions these processes produce. In…

Clinical Consultation Systems: Designing for the Physician as Computer User

PubMed Central

Shortliffe, Edward H.

1981-01-01

The barriers to successful implementation of consultation systems for physicians have been frequently discussed. Our research has been directed at the development of computer techniques that will heighten the acceptance of high performance decision making tools. We discuss two current projects at Stanford Medical School that address both practical and theoretical issues in the design and construction of clinically useful systems.

Joint Participation in Decision Making: A Study of Faculty Government and Faculty-Administrative Consultation at Fresno State College.

ERIC Educational Resources Information Center

Deegan, W. L.; And Others

This is one of a group of studies on faculty organization and faculty government. Fresno State College was studied for (1) the nature and effectiveness of the procedures that had been devised for faculty-administrative consultation, (2) the process of faculty and administrative participation in governance through the Academic Senate and selected…

20 CFR 404.1519o - When a properly signed consultative examination report has not been received.

Code of Federal Regulations, 2010 CFR

2010-04-01

... Standards for the Type of Referral and for Report Content § 404.1519o When a properly signed consultative... examination has died: (1) Continuous period of disability allowance with an onset date as alleged or earlier than alleged; or (2) Continuance of disability. (b) When we will not make determinations and decisions...

Social Power and Influence: Understanding Its Relevance in Early Childhood Consultation

ERIC Educational Resources Information Center

Spino, Margie A.; Dinnebeil, Laurie A.; McInerney, William F.

2013-01-01

The purpose of this article is to introduce and describe a model of social power and influence developed by Erchul and Raven (1997). This model describes the decision-making process a consultant would engage in to choose, implement, evaluate as well as the use of strategies that they might use to influence another person to act in a particular…

The common practice of "curbside consultation": A systematic review.

PubMed

Papermaster, Amy; Champion, Jane Dimmitt

2017-10-01

Point-of-care information needs for nurse practitioners are tremendous. A phenomenon often referred to as curbside consultation (CC) with colleagues is an information source for point-of-care clinical decision making. This literature review was conducted to describe: (a) characteristics of CC, (b) consistency of CC definition, and (c) attitudes about CC among health professionals using this information source for point-of-care clinical decision making. This literature review includes research conducted from 1980 to 2016 concerning CC among health professionals. Data bases including PubMed, CINAHL, Google Scholar, Web of Science, PsychInfo, Business Source, and Cochrane Library were searched resulting in 15 articles for inclusion in this review. Fink's recommendations were used to assess study bias risk. Only studies including physician samples met inclusion criteria. These studies, primarily from consultant perspectives, were conducted in varied settings and were considered highly valuable. CC s averaging 9.4 min were defined as informal advice and information-seeking without formal consultation. A paucity of information exists concerning CC use among nurse practitioners. An assessment of CC processes among nurse practitioners is indicated to inform education and practice for research dissemination ultimately promoting patient care quality. ©2017 American Association of Nurse Practitioners.

Emotional communication in medical consultations with native and non-native patients applying two different methodological approaches.

PubMed

Kale, Emine; Skjeldestad, Kristin; Finset, Arnstein

2013-09-01

To explore the potential agreement between two different methods to investigate emotional communication of native and non-native patients in medical consultations. The data consisted of 12 videotaped hospital consultations with six native and six non-native patients. The consultations were coded according to coding rules of the Verona Coding definitions of Emotional Sequences (VR-CoDES) and afterwards analyzed by discourse analysis (DA) by two co-workers who were blind to the results from VR-CoDES. The agreement between VR-CoDES and DA was high in consultations with many cues and concerns, both with native and non-native patients. In consultations with no (or one cue) according to VR-CoDES criteria the DA still indicated the presence of emotionally salient expressions and themes. In some consultations cues to underlying emotions are communicated so vaguely or veiled by language barriers that standard VR-CoDES coding may miss subtle cues. Many of these sub-threshold cues could potentially be coded as cues according to VR-CoDES main coding categories, if criteria for coding vague or ambiguous cues had been better specified. Combining different analytical frameworks on the same dataset provide us new insights on emotional communication. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

Mentally abnormal prisoners on remand: I—Rejected or accepted by the NHS?

PubMed Central

Coid, Jeremy W

1988-01-01

Increasing numbers of mentally abnormal offenders are sentenced to prison. The decision to treat or imprison them is influenced by the attitudes of consultant psychiatrists and their staff. The process whereby those decisions were made and the willingness of consultants to offer treatment were investigated. A retrospective survey of all (362) mentally abnormal men remanded to Winchester prison for psychiatric reports over the five years 1979-83 showed that one in five were rejected for treatment by the NHS consultant psychiatrist responsible for their care. Those with mental handicaps, organic brain damage, or a chronic psychotic illness rendering them unable to cope independently in the community were the most likely to be rejected. They posed the least threat to the community in terms of their criminal behaviour yet were more likely to be sentenced to imprisonment. Such subjects were commonly described by consultants as too disturbed or potentially dangerous to be admitted to hospital or as criminals and unsuitable for treatment. Consultants in mental hospitals were most likely and those in district general hospitals and academic units least likely to accept prisoners. The fact that many mentally ill and mentally handicapped patients can receive adequate care and treatment only on reception into prison raises serious questions about the adequacy of current management policies and the range of facilities provided by regional health authorities. PMID:3136837

Proposed Clinical Decision Rules to Diagnose Acute Rhinosinusitis Among Adults in Primary Care.

PubMed

Ebell, Mark H; Hansen, Jens Georg

2017-07-01

To reduce inappropriate antibiotic prescribing, we sought to develop a clinical decision rule for the diagnosis of acute rhinosinusitis and acute bacterial rhinosinusitis. Multivariate analysis and classification and regression tree (CART) analysis were used to develop clinical decision rules for the diagnosis of acute rhinosinusitis, defined using 3 different reference standards (purulent antral puncture fluid or abnormal finding on a computed tomographic (CT) scan; for acute bacterial rhinosinusitis, we used a positive bacterial culture of antral fluid). Signs, symptoms, C-reactive protein (CRP), and reference standard tests were prospectively recorded in 175 Danish patients aged 18 to 65 years seeking care for suspected acute rhinosinusitis. For each reference standard, we developed 2 clinical decision rules: a point score based on a logistic regression model and an algorithm based on a CART model. We identified low-, moderate-, and high-risk groups for acute rhinosinusitis or acute bacterial rhinosinusitis for each clinical decision rule. The point scores each had between 5 and 6 predictors, and an area under the receiver operating characteristic curve (AUROCC) between 0.721 and 0.767. For positive bacterial culture as the reference standard, low-, moderate-, and high-risk groups had a 16%, 49%, and 73% likelihood of acute bacterial rhinosinusitis, respectively. CART models had an AUROCC ranging from 0.783 to 0.827. For positive bacterial culture as the reference standard, low-, moderate-, and high-risk groups had a likelihood of acute bacterial rhinosinusitis of 6%, 31%, and 59% respectively. We have developed a series of clinical decision rules integrating signs, symptoms, and CRP to diagnose acute rhinosinusitis and acute bacterial rhinosinusitis with good accuracy. They now require prospective validation and an assessment of their effect on clinical and process outcomes. © 2017 Annals of Family Medicine, Inc.

a Workflow for UAV's Integration Into a Geodesign Platform

NASA Astrophysics Data System (ADS)

Anca, P.; Calugaru, A.; Alixandroae, I.; Nazarie, R.

2016-06-01

This paper presents a workflow for the development of various Geodesign scenarios. The subject is important in the context of identifying patterns and designing solutions for a Smart City with optimized public transportation, efficient buildings, efficient utilities, recreational facilities a.s.o.. The workflow describes the procedures starting with acquiring data in the field, data processing, orthophoto generation, DTM generation, integration into a GIS platform and analyzing for a better support for Geodesign. Esri's City Engine is used mostly for 3D modeling capabilities that enable the user to obtain 3D realistic models. The workflow uses as inputs information extracted from images acquired using UAVs technologies, namely eBee, existing 2D GIS geodatabases, and a set of CGA rules. The method that we used further, is called procedural modeling, and uses rules in order to extrude buildings, the street network, parcel zoning and side details, based on the initial attributes from the geodatabase. The resulted products are various scenarios for redesigning, for analyzing new exploitation sites. Finally, these scenarios can be published as interactive web scenes for internal, groups or pubic consultation. In this way, problems like the impact of new constructions being build, re-arranging green spaces or changing routes for public transportation, etc. are revealed through impact and visibility analysis or shadowing analysis and are brought to the citizen's attention. This leads to better decisions.

Decision support system for triage management: A hybrid approach using rule-based reasoning and fuzzy logic.

PubMed

Dehghani Soufi, Mahsa; Samad-Soltani, Taha; Shams Vahdati, Samad; Rezaei-Hachesu, Peyman

2018-06-01

Fast and accurate patient triage for the response process is a critical first step in emergency situations. This process is often performed using a paper-based mode, which intensifies workload and difficulty, wastes time, and is at risk of human errors. This study aims to design and evaluate a decision support system (DSS) to determine the triage level. A combination of the Rule-Based Reasoning (RBR) and Fuzzy Logic Classifier (FLC) approaches were used to predict the triage level of patients according to the triage specialist's opinions and Emergency Severity Index (ESI) guidelines. RBR was applied for modeling the first to fourth decision points of the ESI algorithm. The data relating to vital signs were used as input variables and modeled using fuzzy logic. Narrative knowledge was converted to If-Then rules using XML. The extracted rules were then used to create the rule-based engine and predict the triage levels. Fourteen RBR and 27 fuzzy rules were extracted and used in the rule-based engine. The performance of the system was evaluated using three methods with real triage data. The accuracy of the clinical decision support systems (CDSSs; in the test data) was 99.44%. The evaluation of the error rate revealed that, when using the traditional method, 13.4% of the patients were miss-triaged, which is statically significant. The completeness of the documentation also improved from 76.72% to 98.5%. Designed system was effective in determining the triage level of patients and it proved helpful for nurses as they made decisions, generated nursing diagnoses based on triage guidelines. The hybrid approach can reduce triage misdiagnosis in a highly accurate manner and improve the triage outcomes. Copyright © 2018 Elsevier B.V. All rights reserved.

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

PubMed

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

2015-07-01

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

Failure detection system design methodology. Ph.D. Thesis

NASA Technical Reports Server (NTRS)

Chow, E. Y.

1980-01-01

The design of a failure detection and identification system consists of designing a robust residual generation process and a high performance decision making process. The design of these two processes are examined separately. Residual generation is based on analytical redundancy. Redundancy relations that are insensitive to modelling errors and noise effects are important for designing robust residual generation processes. The characterization of the concept of analytical redundancy in terms of a generalized parity space provides a framework in which a systematic approach to the determination of robust redundancy relations are developed. The Bayesian approach is adopted for the design of high performance decision processes. The FDI decision problem is formulated as a Bayes sequential decision problem. Since the optimal decision rule is incomputable, a methodology for designing suboptimal rules is proposed. A numerical algorithm is developed to facilitate the design and performance evaluation of suboptimal rules.

Textural features for image classification

NASA Technical Reports Server (NTRS)

Haralick, R. M.; Dinstein, I.; Shanmugam, K.

1973-01-01

Description of some easily computable textural features based on gray-tone spatial dependances, and illustration of their application in category-identification tasks of three different kinds of image data - namely, photomicrographs of five kinds of sandstones, 1:20,000 panchromatic aerial photographs of eight land-use categories, and ERTS multispectral imagery containing several land-use categories. Two kinds of decision rules are used - one for which the decision regions are convex polyhedra (a piecewise-linear decision rule), and one for which the decision regions are rectangular parallelpipeds (a min-max decision rule). In each experiment the data set was divided into two parts, a training set and a test set. Test set identification accuracy is 89% for the photomicrographs, 82% for the aerial photographic imagery, and 83% for the satellite imagery. These results indicate that the easily computable textural features probably have a general applicability for a wide variety of image-classification applications.

19 CFR 177.13 - Inconsistent customs decisions.

Code of Federal Regulations, 2010 CFR

2010-04-01

... 19 Customs Duties 2 2010-04-01 2010-04-01 false Inconsistent customs decisions. 177.13 Section 177.13 Customs Duties U.S. CUSTOMS AND BORDER PROTECTION, DEPARTMENT OF HOMELAND SECURITY; DEPARTMENT OF THE TREASURY (CONTINUED) ADMINISTRATIVE RULINGS General Ruling Procedure § 177.13 Inconsistent customs...

19 CFR 177.13 - Inconsistent customs decisions.

Code of Federal Regulations, 2012 CFR

2012-04-01

... 19 Customs Duties 2 2012-04-01 2012-04-01 false Inconsistent customs decisions. 177.13 Section 177.13 Customs Duties U.S. CUSTOMS AND BORDER PROTECTION, DEPARTMENT OF HOMELAND SECURITY; DEPARTMENT OF THE TREASURY (CONTINUED) ADMINISTRATIVE RULINGS General Ruling Procedure § 177.13 Inconsistent customs...

19 CFR 177.13 - Inconsistent customs decisions.

Code of Federal Regulations, 2011 CFR

2011-04-01

... 19 Customs Duties 2 2011-04-01 2011-04-01 false Inconsistent customs decisions. 177.13 Section 177.13 Customs Duties U.S. CUSTOMS AND BORDER PROTECTION, DEPARTMENT OF HOMELAND SECURITY; DEPARTMENT OF THE TREASURY (CONTINUED) ADMINISTRATIVE RULINGS General Ruling Procedure § 177.13 Inconsistent customs...

47 CFR 73.3613 - Filing of contracts.

Code of Federal Regulations, 2010 CFR

2010-10-01

... following: (1) Articles of partnership, association, and incorporation, and changes in such instruments; (2... of this rule provision. (c) Personnel: (1) Management consultant agreements with independent contractors; contracts relating to the utilization in a management capacity of any person other than an...

48 CFR 9901.305 - Requirements for standards and interpretive rulings.

Code of Federal Regulations, 2014 CFR

2014-10-01

... promulgation of cost accounting standards and interpretations thereof, the Board shall: (a) Take into account, after consultation and discussion with the Comptroller General, professional accounting organizations... ACCOUNTING STANDARDS BOARD, OFFICE OF FEDERAL PROCUREMENT POLICY, OFFICE OF MANAGEMENT AND BUDGET...

48 CFR 9901.305 - Requirements for standards and interpretive rulings.

Code of Federal Regulations, 2013 CFR

2013-10-01

... promulgation of cost accounting standards and interpretations thereof, the Board shall: (a) Take into account, after consultation and discussion with the Comptroller General, professional accounting organizations... ACCOUNTING STANDARDS BOARD, OFFICE OF FEDERAL PROCUREMENT POLICY, OFFICE OF MANAGEMENT AND BUDGET...

48 CFR 9901.305 - Requirements for standards and interpretive rulings.

Code of Federal Regulations, 2011 CFR

2011-10-01

... promulgation of cost accounting standards and interpretations thereof, the Board shall: (a) Take into account, after consultation and discussion with the Comptroller General, professional accounting organizations... ACCOUNTING STANDARDS BOARD, OFFICE OF FEDERAL PROCUREMENT POLICY, OFFICE OF MANAGEMENT AND BUDGET...

48 CFR 9901.305 - Requirements for standards and interpretive rulings.

Code of Federal Regulations, 2012 CFR

2012-10-01

... promulgation of cost accounting standards and interpretations thereof, the Board shall: (a) Take into account, after consultation and discussion with the Comptroller General, professional accounting organizations... ACCOUNTING STANDARDS BOARD, OFFICE OF FEDERAL PROCUREMENT POLICY, OFFICE OF MANAGEMENT AND BUDGET...

48 CFR 9901.305 - Requirements for standards and interpretive rulings.

Code of Federal Regulations, 2010 CFR

2010-10-01

... promulgation of cost accounting standards and interpretations thereof, the Board shall: (a) Take into account, after consultation and discussion with the Comptroller General, professional accounting organizations... ACCOUNTING STANDARDS BOARD, OFFICE OF FEDERAL PROCUREMENT POLICY, OFFICE OF MANAGEMENT AND BUDGET...

Unexplained Weight Loss

MedlinePlus

... weight is affected by your calorie intake, activity level, overall health, age, nutrient absorption, and economic and social factors. If you're losing weight without trying and you're concerned about it, consult your doctor — as a rule of thumb, losing more than 5 ...

77 FR 60318 - Procedures for Transportation Workplace Drug and Alcohol Testing Programs: 6-acetylmorphine (6-AM...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-10-03

... final rule to harmonize with many aspects of the revised Department of Health and Human Services (HHS... (ODAPC). After consulting with ODAPC, the MRO would make a verified result determination, keeping in mind...

23 CFR 450.210 - Interested parties, public involvement, and consultation.

Code of Federal Regulations, 2012 CFR

2012-04-01

... opportunities for public review and comment at key decision points. (1) The State's public involvement process... agencies, representatives of public transportation employees, freight shippers, private providers of... comment at key decision points, including but not limited to a reasonable opportunity to comment on the...

23 CFR 450.210 - Interested parties, public involvement, and consultation.

Code of Federal Regulations, 2013 CFR

2013-04-01

... opportunities for public review and comment at key decision points. (1) The State's public involvement process... agencies, representatives of public transportation employees, freight shippers, private providers of... comment at key decision points, including but not limited to a reasonable opportunity to comment on the...

23 CFR 450.210 - Interested parties, public involvement, and consultation.

Code of Federal Regulations, 2014 CFR

2014-04-01

... opportunities for public review and comment at key decision points. (1) The State's public involvement process... agencies, representatives of public transportation employees, freight shippers, private providers of... comment at key decision points, including but not limited to a reasonable opportunity to comment on the...

Interventions to facilitate shared decision making to address antibiotic use for acute respiratory infections in primary care.

PubMed

Coxeter, Peter; Del Mar, Chris B; McGregor, Leanne; Beller, Elaine M; Hoffmann, Tammy C

2015-11-12

Shared decision making is an important component of patient-centred care. It is a set of communication and evidence-based practice skills that elicits patients' expectations, clarifies any misperceptions and discusses the best available evidence for benefits and harms of treatment. Acute respiratory infections (ARIs) are one of the most common reasons for consulting in primary care and obtaining prescriptions for antibiotics. However, antibiotics offer few benefits for ARIs, and their excessive use contributes to antibiotic resistance - an evolving public health crisis. Greater explicit consideration of the benefit-harm trade-off within shared decision making may reduce antibiotic prescribing for ARIs in primary care. To assess whether interventions that aim to facilitate shared decision making increase or reduce antibiotic prescribing for ARIs in primary care. We searched CENTRAL (2014, Issue 11), MEDLINE (1946 to November week 3, 2014), EMBASE (2010 to December 2014) and Web of Science (1985 to December 2014). We searched for other published, unpublished or ongoing trials by searching bibliographies of published articles, personal communication with key trial authors and content experts, and by searching trial registries at the National Institutes of Health and the World Health Organization. Randomised controlled trials (RCTs) (individual level or cluster-randomised), which evaluated the effectiveness of interventions that promote shared decision making (as the focus or a component of the intervention) about antibiotic prescribing for ARIs in primary care. Two review authors independently extracted and collected data. Antibiotic prescribing was the primary outcome, and secondary outcomes included clinically important adverse endpoints (e.g. re-consultations, hospital admissions, mortality) and process measures (e.g. patient satisfaction). We assessed the risk of bias of all included trials and the quality of evidence. We contacted trial authors to obtain missing information where available. We identified 10 published reports of nine original RCTs (one report was a long-term follow-up of the original trial) in over 1100 primary care doctors and around 492,000 patients.The main risk of bias came from participants in most studies knowing whether they had received the intervention or not, and we downgraded the rating of the quality of evidence because of this.We meta-analysed data using a random-effects model on the primary and key secondary outcomes and formally assessed heterogeneity. Remaining outcomes are presented narratively.There is moderate quality evidence that interventions that aim to facilitate shared decision making reduce antibiotic use for ARIs in primary care (immediately after or within six weeks of the consultation), compared with usual care, from 47% to 29%: risk ratio (RR) 0.61, 95% confidence interval (CI) 0.55 to 0.68. Reduction in antibiotic prescribing occurred without an increase in patient-initiated re-consultations (RR 0.87, 95% CI 0.74 to 1.03, moderate quality evidence) or a decrease in patient satisfaction with the consultation (OR 0.86, 95% CI 0.57 to 1.30, low quality evidence). There were insufficient data to assess the effects of the intervention on sustained reduction in antibiotic prescribing, adverse clinical outcomes (such as hospital admission, incidence of pneumonia and mortality), or measures of patient and caregiver involvement in shared decision making (such as satisfaction with the consultation; regret or conflict with the decision made; or treatment compliance following the decision). No studies assessed antibiotic resistance in colonising or infective organisms. Interventions that aim to facilitate shared decision making reduce antibiotic prescribing in primary care in the short term. Effects on longer-term rates of prescribing are uncertain and more evidence is needed to determine how any sustained reduction in antibiotic prescribing affects hospital admission, pneumonia and death.

More counselling for end-of-life decisions by GPs with own advance directives: A postal survey among German general practitioners.

PubMed

Schnakenberg, Rieke; Radbruch, Lukas; Kersting, Christine; Frank, Friederike; Wilm, Stefan; Becka, Denise; Weckbecker, Klaus; Bleckwenn, Markus; Just, Johannes M; Pentzek, Michael; Weltermann, Birgitta

2018-12-01

Although general practitioners (GPs) are among the preferred contact persons for discussing end-of-life issues including advance directives (ADs), there is little data on how GPs manage such consultations. This postal survey asked German GPs about their counselling for end-of-life decisions. In 2015, a two-sided questionnaire was mailed to 959 GPs. GPs were asked for details of their consultations on ADs: frequency, duration, template use, and whether they have own ADs. Statistical analysis evaluated physician characteristics associated with an above-average number of consultations on AD. The participation rate was 50.3% (n = 482), 70.5% of the GPs were male; the average age was 54 years. GPs had an average of 18 years of professional experience, and 61.4% serve more than 900 patients per three months. Most (96.9%) GPs perform consultations on living wills (LW) and/or powers of attorney (PA), mainly in selected patients (72.3%). More than 20 consultations each on LWs and PAs are performed by 60% and 50% of GPs, respectively. The estimated mean duration of consultations was 21 min for LWs and 16 min for PAs. Predefined templates were used in 72% of the GPs, 50% of GPs had their ADs. A statistical model showed that GPs with ADs and/or a qualification in palliative medicine were more likely to counsel ≥20 patients per year for each document. The study confirmed that nearly all German GPs surveyed provide counselling on ADs. Physicians with ADs counsel more frequently than those without such documents.

Parents' information needs, self-efficacy and influences on consulting for childhood respiratory tract infections: a qualitative study.

PubMed

Ingram, Jenny; Cabral, Christie; Hay, Alastair D; Lucas, Patricia J; Horwood, Jeremy

2013-07-28

Acute respiratory tract infection (RTI) is the most common reason why parents consult primary care in the UK. Little is known about parents' perceptions of what may help them to make an appropriate decision to consult when their child is ill and how to improve self-care.Using qualitative methods, this study aimed to explore parents' views on support and information needs prior to consulting when children have RTIs with cough, and identify the triggers and barriers to consulting primary care. 7 focus groups and 30 semi-structured interviews were held with 60 parents (with children aged 5 months - 17 years) from a range of socio-economic backgrounds. Topics discussed were informed by the Health Belief Model, and explored parents' concerns and beliefs about susceptibility and severity of RTIs, beliefs about the triggers and barriers to consulting, and information and support seeking behaviour undertaken before consulting primary care. Discussions were audio-recorded, transcribed and analysed using thematic methods. Parents from all socio-economic backgrounds sought information from a wide range of sources about RTIs in children in order to identify which of their child's symptoms should be of concern and trigger a visit to the doctor. The perception of threat to a child of RTI (with cough) was increased with more severe illness and by perceived susceptibility to illness of a particular child; whilst experience with other children increased parental efficacy to cope with childhood cough at home. Psychological models of health behaviour informed the understanding of cultural beliefs and attitudes that underpin health related behaviours. A wide range of perceptions influence the likelihood that parents will seek help from primary care for a child with cough; these perceptions are similar across socio-economic groups. Parents' experience, confidence and efficacy influence the likelihood of consulting primary care for their child's RTI. Parents would value consistent advice from a trusted source that addresses common concerns and supports home care and decision making about help seeking.

Learning stage-dependent effect of M1 disruption on value-based motor decisions.

PubMed

Derosiere, Gerard; Vassiliadis, Pierre; Demaret, Sophie; Zénon, Alexandre; Duque, Julie

2017-11-15

The present study aimed at characterizing the impact of M1 disruption on the implementation of implicit value information in motor decisions, at both early stages (during reinforcement learning) and late stages (after consolidation) of action value encoding. Fifty subjects performed, over three consecutive days, a task that required them to select between two finger responses according to the color (instruction) and to the shape (implicit, undisclosed rule) of an imperative signal: considering the implicit rule in addition to the instruction allowed subjects to earn more money. We investigated the functional contribution of M1 to the implementation of the implicit rule in subjects' motor decisions. Continuous theta burst stimulation (cTBS) was applied over M1 either on Day 1 or on Day 3, producing a temporary lesion either during reinforcement learning (cTBS Learning group) or after consolidation of the implicit rule, during decision-making (cTBS Decision group), respectively. Interestingly, disrupting M1 activity on Day 1 improved the reliance on the implicit rule, plausibly because M1 cTBS increased dopamine release in the putamen in an indirect way. This finding corroborates the view that cTBS may affect activity in unstimulated areas, such as the basal ganglia. Notably, this effect was short-lasting; it did not persist overnight, suggesting that the functional integrity of M1 during learning is a prerequisite for the consolidation of implicit value information to occur. Besides, cTBS over M1 did not impact the use of the implicit rule when applied on Day 3, although it did so when applied on Day 2 in a recent study where the reliance on the implicit rule declined following cTBS (Derosiere et al., 2017). Overall, these findings indicate that the human M1 is functionally involved in the consolidation and implementation of implicit value information underlying motor decisions. However, M1 contribution seems to vanish as subjects become more experienced in using the implicit value information to make their motor decisions. Copyright © 2017 Elsevier Inc. All rights reserved.

The Cape Town Clinical Decision Rule for Streptococcal Pharyngitis in Children

PubMed Central

Engel, Mark Emmanuel; Cohen, Karen; Gounden, Ronald; Kengne, Andre P.; Barth, Dylan Dominic; Whitelaw, Andrew C; Francis, Veronica; Badri, Motasim; Stewart, Annemie; Dale, James B.; Mayosi, Bongani M.; Maartens, Gary

2016-01-01

Background Existing clinical decision rules (CDR) to diagnose group A streptococcal (GAS) pharyngitis have not been validated in sub-Saharan Africa. We developed a locally applicable CDR while evaluating existing CDRs for diagnosing GAS pharyngitis in South African children. Methods We conducted a prospective cohort study and enrolled 997 children aged 3-15 years presenting to primary care clinics with a complaint of sore throat, and whose parents provided consent. Main outcome measures were signs and symptoms of pharyngitis, and a positive GAS culture from a throat swab. Bivariate and multivariate analyses were used to develop the clinical decision rule. In addition, the diagnostic effectiveness of six existing rules for predicting a positive culture in our cohort was assessed. Results 206 of 982 children (21%) had a positive GAS culture. Tonsillar swelling, tonsillar exudates, tender or enlarged anterior cervical lymph nodes, absence of cough and absence of rhinorrhea were associated with positive cultures in bivariate and multivariate analyses. Four variables (tonsillar swelling and one of tonsillar exudate, no rhinorrhea, no cough), when used in a cumulative score, showed 83.7% sensitivity and 32.2% specificity for GAS pharyngitis. Of existing rules tested, the McIsaac rule had the highest positive predictive value (28%), but missed 49% of the culture-positive children who should have been treated. Conclusion The new four-variable clinical decision rule for GAS pharyngitis (i.e., tonsillar swelling and one of tonsillar exudate, no rhinorrhea, no cough) outperformed existing rules for GAS pharyngitis diagnosis in children with symptomatic sore throat in Cape Town. PMID:27870815

Characterising bias in regulatory risk and decision analysis: An analysis of heuristics applied in health technology appraisal, chemicals regulation, and climate change governance.

PubMed

MacGillivray, Brian H

2017-08-01

In many environmental and public health domains, heuristic methods of risk and decision analysis must be relied upon, either because problem structures are ambiguous, reliable data is lacking, or decisions are urgent. This introduces an additional source of uncertainty beyond model and measurement error - uncertainty stemming from relying on inexact inference rules. Here we identify and analyse heuristics used to prioritise risk objects, to discriminate between signal and noise, to weight evidence, to construct models, to extrapolate beyond datasets, and to make policy. Some of these heuristics are based on causal generalisations, yet can misfire when these relationships are presumed rather than tested (e.g. surrogates in clinical trials). Others are conventions designed to confer stability to decision analysis, yet which may introduce serious error when applied ritualistically (e.g. significance testing). Some heuristics can be traced back to formal justifications, but only subject to strong assumptions that are often violated in practical applications. Heuristic decision rules (e.g. feasibility rules) in principle act as surrogates for utility maximisation or distributional concerns, yet in practice may neglect costs and benefits, be based on arbitrary thresholds, and be prone to gaming. We highlight the problem of rule-entrenchment, where analytical choices that are in principle contestable are arbitrarily fixed in practice, masking uncertainty and potentially introducing bias. Strategies for making risk and decision analysis more rigorous include: formalising the assumptions and scope conditions under which heuristics should be applied; testing rather than presuming their underlying empirical or theoretical justifications; using sensitivity analysis, simulations, multiple bias analysis, and deductive systems of inference (e.g. directed acyclic graphs) to characterise rule uncertainty and refine heuristics; adopting "recovery schemes" to correct for known biases; and basing decision rules on clearly articulated values and evidence, rather than convention. Copyright © 2017. Published by Elsevier Ltd.

Rule groupings in expert systems using nearest neighbour decision rules, and convex hulls

NASA Technical Reports Server (NTRS)

Anastasiadis, Stergios

1991-01-01

Expert System shells are lacking in many areas of software engineering. Large rule based systems are not semantically comprehensible, difficult to debug, and impossible to modify or validate. Partitioning a set of rules found in CLIPS (C Language Integrated Production System) into groups of rules which reflect the underlying semantic subdomains of the problem, will address adequately the concerns stated above. Techniques are introduced to structure a CLIPS rule base into groups of rules that inherently have common semantic information. The concepts involved are imported from the field of A.I., Pattern Recognition, and Statistical Inference. Techniques focus on the areas of feature selection, classification, and a criteria of how 'good' the classification technique is, based on Bayesian Decision Theory. A variety of distance metrics are discussed for measuring the 'closeness' of CLIPS rules and various Nearest Neighbor classification algorithms are described based on the above metric.

Web-based Weather Expert System (WES) for Space Shuttle Launch

NASA Technical Reports Server (NTRS)

Bardina, Jorge E.; Rajkumar, T.

2003-01-01

The Web-based Weather Expert System (WES) is a critical module of the Virtual Test Bed development to support 'go/no go' decisions for Space Shuttle operations in the Intelligent Launch and Range Operations program of NASA. The weather rules characterize certain aspects of the environment related to the launching or landing site, the time of the day or night, the pad or runway conditions, the mission durations, the runway equipment and landing type. Expert system rules are derived from weather contingency rules, which were developed over years by NASA. Backward chaining, a goal-directed inference method is adopted, because a particular consequence or goal clause is evaluated first, and then chained backward through the rules. Once a rule is satisfied or true, then that particular rule is fired and the decision is expressed. The expert system is continuously verifying the rules against the past one-hour weather conditions and the decisions are made. The normal procedure of operations requires a formal pre-launch weather briefing held on Launch minus 1 day, which is a specific weather briefing for all areas of Space Shuttle launch operations. In this paper, the Web-based Weather Expert System of the Intelligent Launch and range Operations program is presented.

Expert system for skin problem consultation in Thai traditional medicine.

PubMed

Nopparatkiat, Pornchai; na Nagara, Byaporn; Chansa-ngavej, Chuvej

2014-01-01

This paper aimed to demonstrate the research and development of a rule-based expert system for skin problem consulting in the areas of acne, melasma, freckle, wrinkle, and uneven skin tone, with recommended treatments from Thai traditional medicine knowledge. The tool selected for developing the expert system is a software program written in the PHP language. MySQL database is used to work together with PHP for building database of the expert system. The system is web-based and can be reached from anywhere with Internet access. The developed expert system gave recommendations on the skin problem treatment with Thai herbal recipes and Thai herbal cosmetics based on 416 rules derived from primary and secondary sources. The system had been tested by 50 users consisting of dermatologists, Thai traditional medicine doctors, and general users. The developed system was considered good for learning and consultation. The present work showed how such a scattered body of traditional knowledge as Thai traditional medicine and herbal recipes could be collected, organised and made accessible to users and interested parties. The expert system developed herein should contribute in a meaningful way towards preserving the knowledge and helping promote the use of Thai traditional medicine as a practical alternative medicine for the treatment of illnesses.

Characterization of Kentucky dairy producer decision-making behavior.

PubMed

Russell, R A; Bewley, J M

2013-07-01

To address dairy clientele needs, industry professionals need to understand how dairy producers make decisions. A survey was distributed to all licensed Kentucky milk producers (n=1,074) to better understand factors that influence dairy producer decisions. A total of 236 surveys were returned; 7 were omitted because they were incomplete, leaving 229 for subsequent analyses (21% response rate). The survey consisted of questions about dairy operational success criteria, decision evaluation criteria, information sources, and technology adoption. The mean response to each survey question was calculated after assigning the following numeric values to producer response categories: 1 = not important, 3 = important, 5 = very important. The most important source of influence or information in decision making was advice from consultants, nutritionists, and veterinarians (3.70±1.23), followed by consultation with business partners and family members (3.68±1.29), and intuition and gut feeling (3.10±1.45). Producers with large herds (≥200 cows) relied more heavily on information from consultants, nutritionists, and veterinarians and on employee input than did producers with small herds (1 to 49 cows). Producers with small herds did not use effect on employee morale as a criterion to evaluate decisions as much as those with larger herds did. In regard to adoption of automated monitoring technologies, producers indicated that modest adoption rates were a result of (1) not being familiar with technologies that are available (55%), (2) undesirable cost to benefit ratios (42%), and (3) too much information provided without knowing what to do with it (36%). As herd size increased, the percentage of producers selecting poor technical support and training and compatibility issues as reasons for slow adoption of automated technologies increased. This insight into dairy producer decision making should help industry professionals address dairy producer issues and concerns. Copyright © 2013 American Dairy Science Association. Published by Elsevier Inc. All rights reserved.

Validation of the Ottawa Knee Rules.

PubMed

Emparanza, J I; Aginaga, J R

2001-10-01

We sought to validate the Ottawa Knee Rules for determining the need for radiography in patients with acute knee injury. A prospective cohort study was performed in emergency departments of 11 hospitals of the Osakidetza-Basque Country Health Service. The patient population was composed of a convenience sample of 1,522 eligible adults of 2,315 patients with acute knee injuries. The attending emergency physicians assessed each patient for standardized clinical variables and determined the need for radiography according to the decision rule. Radiography was performed in each patient, irrespective of the determination of the rule, after clinical evaluation findings were recorded. The rule was assessed for the ability to correctly identify fracture of the knee. The decision rule had a sensitivity of 1.0 (95% confidence interval [CI] 0.96 to 1.0), identifying 89 patients with clinically important fractures. The potential reduction in use of radiography was estimated to be 49%. The probability of fracture, if the decision rules were negative, is estimated to be 0% (95% CI 0% to 0.5%). Prospective validation has shown the Ottawa Knee Rules to be 100% sensitive for identifying fractures of the knee and to have the potential to allow physicians to reduce the use of radiography in patients with acute knee injuries.

77 FR 32593 - Agency Information Collection Activities; Notice of Intent To Renew Collection: Rules Relating To...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-06-01

... Association decisions in disciplinary, membership denial, registration, and member responsibility actions... and disciplinary actions. The Commission estimates the burden of this collection of information as... Renew Collection: Rules Relating To Review of National Futures Association Decisions in Disciplinary...

19 CFR 177.1 - General ruling practice and definitions.

Code of Federal Regulations, 2010 CFR

2010-04-01

... in applicable Treasury Decisions, rulings, opinions, or court decisions published in the Customs... in response to a written request therefor and set forth in a letter addressed to the person making... more than call attention to a well-established interpretation or principle of Customs law, without...

The biometric imaginary: (Dis)trust in a policy vacuum.

PubMed

Gunnarsdóttir, Kristrún; Rommetveit, Kjetil

2017-02-01

The decision in Europe to implement biometric passports, visas and residence permits was made at the highest levels without much consultation, checks and balances. Council regulation came into force relatively unnoticed in January 2005, as part of wider securitization policies urging systems interoperability and data sharing across borders. This article examines the biometric imaginary that characterizes this European Union decision, dictated by executive powers in the policy vacuum after 9/11 - a depiction of mobility governance, technological necessity and whom/what to trust or distrust, calling upon phantom publics to justify decisions rather than test their grounding. We consult an online blog we operated in 2010 to unravel this imaginary years on. Drawing on Dewey's problem of the public, we discuss this temporary opening of a public space in which the imaginary could be reframed and contested, and how such activities may shape, if at all, relations between politics, publics, policy intervention and societal development.

Overview of USEPA's ORD Technical Outreach and Support Activities on Vapor Intrusion Impacts - 03/2008

EPA Science Inventory

The science of determining, characterizing and managing vapor intrusion risks is constantly evolving. Much remains to be done in assisting regulators, consultants and other decision-makers to make informed decisions in mitigating the problem and reducing these risks. ORD has been...

The Art of Moral Decision Making in Educational Research.

ERIC Educational Resources Information Center

Fetterman, David M.

Moral decision-making is an essential element in educational research. The dilemmas examined and explored in this review were drawn from the author's experience as an ethnographic evaluator and consultant in a bay area educational research corporation for the last five years. The major concerns addressed include: conflicting expectations between…

Efficacy of an evidence-based clinical decision support in primary care practices: a randomized clinical trial.

PubMed

McGinn, Thomas G; McCullagh, Lauren; Kannry, Joseph; Knaus, Megan; Sofianou, Anastasia; Wisnivesky, Juan P; Mann, Devin M

2013-09-23

There is consensus that incorporating clinical decision support into electronic health records will improve quality of care, contain costs, and reduce overtreatment, but this potential has yet to be demonstrated in clinical trials. To assess the influence of a customized evidence-based clinical decision support tool on the management of respiratory tract infections and on the effectiveness of integrating evidence at the point of care. In a randomized clinical trial, we implemented 2 well-validated integrated clinical prediction rules, namely, the Walsh rule for streptococcal pharyngitis and the Heckerling rule for pneumonia. INTERVENTIONS AND MAIN OUTCOMES AND MEASURES: The intervention group had access to the integrated clinical prediction rule tool and chose whether to complete risk score calculators, order medications, and generate progress notes to assist with complex decision making at the point of care. The intervention group completed the integrated clinical prediction rule tool in 57.5% of visits. Providers in the intervention group were significantly less likely to order antibiotics than the control group (age-adjusted relative risk, 0.74; 95% CI, 0.60-0.92). The absolute risk of the intervention was 9.2%, and the number needed to treat was 10.8. The intervention group was significantly less likely to order rapid streptococcal tests compared with the control group (relative risk, 0.75; 95% CI, 0.58-0.97; P= .03). The integrated clinical prediction rule process for integrating complex evidence-based clinical decision report tools is of relevant importance for national initiatives, such as Meaningful Use. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01386047.

Promoting informed choice: evaluating a decision-making tool for family planning clients and providers in Mexico.

PubMed

Kim, Young Mi; Kols, Adrienne; Martin, Antonieta; Silva, David; Rinehart, Ward; Prammawat, Sarah; Johnson, Sarah; Church, Kathryn

2005-12-01

The World Health Organization (WHO) has developed a decision-making tool to be used by providers and clients during family planning visits to improve the quality of services. It is important to examine the tool's usability and its impact on counseling and decision-making processes during family planning consultations. Thirteen providers in Mexico City were videotaped with family planning clients three months before and one month after attending a training session on the WHO decision-making tool. The videotapes were coded for client-provider communication and eye contact, and decision-making behaviors were rated. In-depth interviews and focus group discussions explored clients' and providers' opinions of the tool. After providers began using the decision-making tool, they gave clients more information on family planning, tailored that information more closely to clients' situations and more often discussed HIV/AIDS prevention, dual protection and condom use. Client involvement in the decision-making process and client active communication increased, contributing to a shift from provider-dominated to shared decision making. Clients reported that the tool helped them understand the provider's explanations and made them feel more comfortable talking and asking questions during consultations. After one month of practice with the decision-making tool, most providers felt comfortable with it and found it useful; however, they recommended some changes to the tool to help engage clients in the decision-making process. The decision-making tool was useful both as a job aid for providers and as a decision aid for clients.

Multi-disciplinary decision making in general practice.

PubMed

Kirby, Ann; Murphy, Aileen; Bradley, Colin

2018-04-09

Purpose Internationally, healthcare systems are moving towards delivering care in an integrated manner which advocates a multi-disciplinary approach to decision making. Such an approach is formally encouraged in the management of Atrial Fibrillation patients through the European Society of Cardiology guidelines. Since the emergence of new oral anticoagulants switching between oral anticoagulants (OACs) has become prevalent. This case study considers the role of multi-disciplinary decision making, given the complex nature of the agents. The purpose of this paper is to explore Irish General Practitioners' (GPs) experience of switching between all OACs for Arial Fibrillation (AF) patients; prevalence of multi-disciplinary decision making in OAC switching decisions and seeks to determine the GP characteristics that appear to influence the likelihood of multi-disciplinary decision making. Design/methodology/approach A probit model is used to determine the factors influencing multi-disciplinary decision making and a multinomial logit is used to examine the factors influencing who is involved in the multi-disciplinary decisions. Findings Results reveal that while some multi-disciplinary decision-making is occurring (64 per cent), it is not standard practice despite international guidelines on integrated care. Moreover, there is a lack of patient participation in the decision-making process. Female GPs and GPs who have initiated prescriptions for OACs are more likely to engage in multi-disciplinary decision-making surrounding switching OACs amongst AF patients. GPs with training practices were less likely to engage with cardiac consultants and those in urban areas were more likely to engage with other (non-cardiac) consultants. Originality/value For optimal decision making under uncertainty multi-disciplinary decision-making is needed to make a more informed judgement and to improve treatment decisions and reduce the opportunity cost of making the wrong decision.

Automated diagnosis of coronary artery disease based on data mining and fuzzy modeling.

PubMed

Tsipouras, Markos G; Exarchos, Themis P; Fotiadis, Dimitrios I; Kotsia, Anna P; Vakalis, Konstantinos V; Naka, Katerina K; Michalis, Lampros K

2008-07-01

A fuzzy rule-based decision support system (DSS) is presented for the diagnosis of coronary artery disease (CAD). The system is automatically generated from an initial annotated dataset, using a four stage methodology: 1) induction of a decision tree from the data; 2) extraction of a set of rules from the decision tree, in disjunctive normal form and formulation of a crisp model; 3) transformation of the crisp set of rules into a fuzzy model; and 4) optimization of the parameters of the fuzzy model. The dataset used for the DSS generation and evaluation consists of 199 subjects, each one characterized by 19 features, including demographic and history data, as well as laboratory examinations. Tenfold cross validation is employed, and the average sensitivity and specificity obtained is 62% and 54%, respectively, using the set of rules extracted from the decision tree (first and second stages), while the average sensitivity and specificity increase to 80% and 65%, respectively, when the fuzzification and optimization stages are used. The system offers several advantages since it is automatically generated, it provides CAD diagnosis based on easily and noninvasively acquired features, and is able to provide interpretation for the decisions made.

The impact of the Rasouli decision: a Survey of Canadian intensivists.

PubMed

Cape, David; Fox-Robichaud, Alison; Turgeon, Alexis F; Seely, Andrew; Hall, Richard; Burns, Karen; Singal, Rohit K; Dodek, Peter; Bagshaw, Sean; Sibbald, Robert; Downar, James

2016-03-01

In a landmark 2013 decision, the Supreme Court of Canada (SCC) ruled that the withdrawal of life support in certain circumstances is a treatment requiring patient or substitute decision maker (SDM) consent. How intensive care unit (ICU) physicians perceive this ruling is unknown. To determine physician knowledge of and attitudes towards the SCC decision, as well as the self-reported changes in practice attributed to the decision. We surveyed intensivists at university hospitals across Canada. We used a knowledge test and Likert-scale questions to measure respondent knowledge of and attitudes towards the ruling. We used vignettes to assess decision making in cases of intractable physician-SDM conflict over the management of patients with very poor prognoses. We compared management choices pre-SCC decision versus post-SCC decision versus the subjective, respondent-defined most appropriate choice. Responses were compared across predefined subgroups. We performed qualitative analysis on free-text responses. We received 82 responses (response rate=42%). Respondents reported providing high levels of self-defined inappropriate treatment. Although most respondents reported no change in practice, there was a significant overall shift towards higher intensity and less subjectively appropriate management after the SCC decision. Attitudes to the SCC decision and approaches to disputes over end-of-life (EoL) care in the ICU were highly variable. There were no significant differences among predefined subgroups. Many Canadian ICU physicians report providing a higher intensity of treatment, and less subjectively appropriate treatment, in situations of dispute over EoL care after the Supreme Court of Canada's ruling in Cuthbertson versus Rasouli. 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/

Mock jury trials in Taiwan--paving the ground for introducing lay participation.

PubMed

Huang, Kuo-Chang; Lin, Chang-Ching

2014-08-01

The first mock jury study in Taiwan, in which 279 community members watched a videotaped trial, investigated how jurors' estimates of the relative undesirability of wrongful conviction versus wrongful acquittal predicted individual decisions and how decision rules affected outcomes. The percentage of jurors who viewed wrongful conviction as more undesirable increased from 50.9% to 60.9% after deliberation and jurors' postdeliberation acquittal rate (71.7%) was higher than predeliberation acquittal rate (58.8%). Jurors' estimates of the undesirability of wrongful conviction were not correlated with their predeliberation votes but became positively correlated with their postdeliberation decisions. The unanimous rule facilitated jurors' change of vote, predominantly from conviction to acquittal, than the simple majority rule. Jurors reaching a verdict under the unanimous rule viewed deliberation and the verdict more positively. This study indicates that deliberation can ameliorate the problem of most Taiwanese citizens not viewing wrongful conviction as more undesirable than wrongful acquittal. It also suggests that Taiwan should adopt a unanimous rule for its proposed lay participation system.

Patients' views on the use of an Option Grid for knee osteoarthritis in physiotherapy clinical encounters: An interview study.

PubMed

Kinsey, Katharine; Firth, Jill; Elwyn, Glyn; Edwards, Adrian; Brain, Katherine; Marrin, Katy; Nye, Alan; Wood, Fiona

2017-12-01

Patient decision support tools have been developed as a means of providing accurate and accessible information in order for patients to make informed decisions about their care. Option Grids ™ are a type of decision support tool specifically designed to be used during clinical encounters. To explore patients' views of the Option Grid encounter tool used in clinical consultations with physiotherapists, in comparison with usual care, within a patient population who are likely to be disadvantaged by age and low health literacy. Semi-structured interviews with 72 patients (36 who had been given an Option Grid in their consultation and 36 who had not). Thematic analysis explored patients' understanding of treatment options, perceptions of involvement, and readability and utility of the Option Grid. Interviews suggested that the Option Grid facilitated more detailed discussion about the risks and benefits of a wider range of treatment options for osteoarthritis of the knee. Participants indicated that the Option Grid was clear and aided their understanding of a structured progression of the options as their condition advanced, although it was not clear whether the Option Grid facilitated greater engagement in shared decision making. The Option Grid for osteoarthritis of the knee was well received by patient participants who reported that it helped them to understand their options, and made the notion of choice explicit. Use of Option Grids should be considered within routine consultations. © 2017 The Authors Health Expectations Published by John Wiley & Sons Ltd.

12 CFR 263.38 - Recommended decision and filing of record.

Code of Federal Regulations, 2010 CFR

2010-01-01

... FEDERAL RESERVE SYSTEM RULES OF PRACTICE FOR HEARINGS Uniform Rules of Practice and Procedure § 263.38... expiration of the time allowed for filing reply briefs under § 263.37(b), the administrative law judge shall... the administrative law judge's recommended decision, recommended findings of fact, recommended...

49 CFR 1115.1 - Scope of rule.

Code of Federal Regulations, 2010 CFR

2010-10-01

... other than initial decisions. For each category, this rule describes the types of appeal permitted, the requirements to be observed in filing an appeal, provisions for stay of the action, and the status of the action in the absence of a stay. (c) Appeals from the decisions of employees acting under authority...

12 CFR 622.12 - Proposed findings and conclusions; recommended decision.

Code of Federal Regulations, 2010 CFR

2010-01-01

... 12 Banks and Banking 6 2010-01-01 2010-01-01 false Proposed findings and conclusions; recommended decision. 622.12 Section 622.12 Banks and Banking FARM CREDIT ADMINISTRATION FARM CREDIT SYSTEM RULES OF PRACTICE AND PROCEDURE Rules Applicable to Formal Hearings § 622.12 Proposed findings and conclusions...

10 CFR 110.50 - Terms.

Code of Federal Regulations, 2010 CFR

2010-01-01

... provisions of the Atomic Energy Act and to all applicable rules, regulations, decisions and orders of the... conditions when required by amendments of the Atomic Energy Act or other applicable law, or by other rules, regulations, decisions or orders issued in accordance with the terms of the Atomic Energy Act or other...

19 CFR 177.2 - Submission of ruling requests.

Code of Federal Regulations, 2010 CFR

2010-04-01

... Headquarters Office will prepare final decisions under § 177.11 (Requests for Advice by Field Officers), or § 174.23 (Further Review of Protests), § 177.10 (Change of Practice), decisions under part 175 of this... Carrier rulings should be addressed to the Commissioner of Customs and Border Protection, Attention...

17 CFR 201.411 - Commission consideration of initial decisions by hearing officers.

Code of Federal Regulations, 2010 CFR

2010-04-01

... 17 Commodity and Securities Exchanges 2 2010-04-01 2010-04-01 false Commission consideration of initial decisions by hearing officers. 201.411 Section 201.411 Commodity and Securities Exchanges SECURITIES AND EXCHANGE COMMISSION RULES OF PRACTICE Rules of Practice Appeal to the Commission and...

76 FR 37274 - Outer Continental Shelf Air Regulations Consistency Update for Alaska

Federal Register 2010, 2011, 2012, 2013, 2014

2011-06-27

... and prevents EPA from making substantive changes to the requirements it incorporates. As a result, EPA... narrative discussing how EPA made the decision to include or exclude rules. The Alaska Eskimo Whaling Commission expressed specific concern with EPA's decision to exclude administrative and procedural rules and...

Peer-to-Peer Consultations: Ancillary Services Peer Exchange with India: Experience from South Africa, Europe & the United States (Fact Sheet)

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

Not Available

In support of national and subnational decision makers, the 21st Century Power Partnership regularly works with country partners to organize peer-to-peer consultations on critical issues. In March 2014, 21CPP collaborated with the Regulatory Assistance Project - India to host two peer-to-peer exchanges among experts from India, South Africa, Europe, and the United States to discuss the provision of ancillary services, particularly in the context of added variability and uncertainty from renewable energy. This factsheet provides a high level summary of the peer-to-peer consultation.

An automated approach to the design of decision tree classifiers

NASA Technical Reports Server (NTRS)

Argentiero, P.; Chin, R.; Beaudet, P.

1982-01-01

An automated technique is presented for designing effective decision tree classifiers predicated only on a priori class statistics. The procedure relies on linear feature extractions and Bayes table look-up decision rules. Associated error matrices are computed and utilized to provide an optimal design of the decision tree at each so-called 'node'. A by-product of this procedure is a simple algorithm for computing the global probability of correct classification assuming the statistical independence of the decision rules. Attention is given to a more precise definition of decision tree classification, the mathematical details on the technique for automated decision tree design, and an example of a simple application of the procedure using class statistics acquired from an actual Landsat scene.

Primary motor cortex contributes to the implementation of implicit value-based rules during motor decisions.

PubMed

Derosiere, Gerard; Zénon, Alexandre; Alamia, Andrea; Duque, Julie

2017-02-01

In the present study, we investigated the functional contribution of the human primary motor cortex (M1) to motor decisions. Continuous theta burst stimulation (cTBS) was used to alter M1 activity while participants performed a decision-making task in which the reward associated with the subjects' responses (right hand finger movements) depended on explicit and implicit value-based rules. Subjects performed the task over two consecutive days and cTBS occurred in the middle of Day 2, once the subjects were just about to implement implicit rules, in addition to the explicit instructions, to choose their responses, as evident in the control group (cTBS over the right somatosensory cortex). Interestingly, cTBS over the left M1 prevented subjects from implementing the implicit value-based rule while its implementation was enhanced in the group receiving cTBS over the right M1. Hence, cTBS had opposite effects depending on whether it was applied on the contralateral or ipsilateral M1. The use of the explicit value-based rule was unaffected by cTBS in the three groups of subject. Overall, the present study provides evidence for a functional contribution of M1 to the implementation of freshly acquired implicit rules, possibly through its involvement in a cortico-subcortical network controlling value-based motor decisions. Copyright © 2016 Elsevier Inc. All rights reserved.

Real-Time Internet Connections: Implications for Surgical Decision Making in Laparoscopy

PubMed Central

Broderick, Timothy J.; Harnett, Brett M.; Doarn, Charles R.; Rodas, Edgar B.; Merrell, Ronald C.

2001-01-01

Objective To determine whether a low-bandwidth Internet connection can provide adequate image quality to support remote real-time surgical consultation. Summary Background Data Telemedicine has been used to support care at a distance through the use of expensive equipment and broadband communication links. In the past, the operating room has been an isolated environment that has been relatively inaccessible for real-time consultation. Recent technological advances have permitted videoconferencing over low-bandwidth, inexpensive Internet connections. If these connections are shown to provide adequate video quality for surgical applications, low-bandwidth telemedicine will open the operating room environment to remote real-time surgical consultation. Methods Surgeons performing a laparoscopic cholecystectomy in Ecuador or the Dominican Republic shared real-time laparoscopic images with a panel of surgeons at the parent university through a dial-up Internet account. The connection permitted video and audio teleconferencing to support real-time consultation as well as the transmission of real-time images and store-and-forward images for observation by the consultant panel. A total of six live consultations were analyzed. In addition, paired local and remote images were “grabbed” from the video feed during these laparoscopic cholecystectomies. Nine of these paired images were then placed into a Web-based tool designed to evaluate the effect of transmission on image quality. Results The authors showed for the first time the ability to identify critical anatomic structures in laparoscopy over a low-bandwidth connection via the Internet. The consultant panel of surgeons correctly remotely identified biliary and arterial anatomy during six laparoscopic cholecystectomies. Within the Web-based questionnaire, 15 surgeons could not blindly distinguish the quality of local and remote laparoscopic images. Conclusions Low-bandwidth, Internet-based telemedicine is inexpensive, effective, and almost ubiquitous. Use of these inexpensive, portable technologies will allow sharing of surgical procedures and decisions regardless of location. Internet telemedicine consistently supported real-time intraoperative consultation in laparoscopic surgery. The implications are broad with respect to quality improvement and diffusion of knowledge as well as for basic consultation. PMID:11505061

18 CFR 385.702 - Definitions (Rule 702).

Code of Federal Regulations, 2010 CFR

2010-04-01

... 18 Conservation of Power and Water Resources 1 2010-04-01 2010-04-01 false Definitions (Rule 702). 385.702 Section 385.702 Conservation of Power and Water Resources FEDERAL ENERGY REGULATORY COMMISSION, DEPARTMENT OF ENERGY PROCEDURAL RULES RULES OF PRACTICE AND PROCEDURE Decisions § 385.702 Definitions (Rule...

Computed tomography use in minor head injury: attitudes and practices of emergency physicians, neurosurgeons, and radiologists in Turkey.

PubMed

Özan, Ebru; Ataç, Gökçe Kaan

2018-03-01

We aimed to determine the attitudes and practices of emergency physicians (EPs), neurosurgeons, and radiologists in Turkey regarding computed tomography (CT) use for adults with minor head injury (MHI). This cross-sectional study was conducted between August 2015 and October 2016 after obtaining the approval of the institutional ethical committee. The purpose of this study was disclosed to the participants prior to beginning the survey. The study was performed conducting a questionnaire via e-mail on three groups of participants including EPs, neurosurgeons, and radiologists. Participants comprised academic staff at university hospitals as well as department chiefs, specialists, and residents working at university, government, and private hospitals, all of whom are in charge of evaluating MHI patients. A total of 607 participants including 201 (33.1%) EPs, 179 (29.5%) neurosurgeons, and 227 (37.4%) radiologists responded to the survey; 31% of the participants reported awareness and 27.3% reported use of head CT rules in MHI. Awareness and use of the rules were most prominent in EPs group, while the lowest rates were observed in radiologists group (p<0.01). The leading factors inhibiting the use of head CT rules in MHI stated by EPs were medicolegal anxiety (73.6%), expectations of patients and/or patient relatives (72.6%), and time constraints (44.3%). The leading factors stated by neurosurgeons were medicolegal anxiety (60.9%) and expectations of patient and/or patient relatives (46.4%); "not being consulted in the decision-making process to obtain CT in MHI" (65.6%) and medicolegal anxiety (49.8%) were the leading factors stated by radiologists. The results of our study show that many physicians in Turkey do not have favorable attitudes regarding head CT rules in MHI. Medicolegal anxiety, expectations of patient and/or patient relatives, time constraints, wide availability of CT, and lack of adequate education on radiation protection or on patient dose from imaging are the common reasons for this practice pattern.

A clinical return-to-work rule for patients with back pain.

PubMed

Dionne, Clermont E; Bourbonnais, Renée; Frémont, Pierre; Rossignol, Michel; Stock, Susan R; Larocque, Isabelle

2005-06-07

Tools for early identification of workers with back pain who are at high risk of adverse occupational outcome would help concentrate clinical attention on the patients who need it most, while helping reduce unnecessary interventions (and costs) among the others. This study was conducted to develop and validate clinical rules to predict the 2-year work disability status of people consulting for nonspecific back pain in primary care settings. This was a 2-year prospective cohort study conducted in 7 primary care settings in the Quebec City area. The study enrolled 1007 workers (participation, 68.4% of potential participants expected to be eligible) aged 18-64 years who consulted for nonspecific back pain associated with at least 1 day's absence from work. The majority (86%) completed 5 telephone interviews documenting a large array of variables. Clinical information was abstracted from the medical files. The outcome measure was "return to work in good health" at 2 years, a variable that combined patients' occupational status, functional limitations and recurrences of work absence. Predictive models of 2-year outcome were developed with a recursive partitioning approach on a 40% random sample of our study subjects, then validated on the rest. The best predictive model included 7 baseline variables (patient's recovery expectations, radiating pain, previous back surgery, pain intensity, frequent change of position because of back pain, irritability and bad temper, and difficulty sleeping) and was particularly efficient at identifying patients with no adverse occupational outcome (negative predictive value 78%- 94%). A clinical prediction rule accurately identified a large proportion of workers with back pain consulting in a primary care setting who were at a low risk of an adverse occupational outcome.

A clinical return-to-work rule for patients with back pain

PubMed Central

Dionne, Clermont E.; Bourbonnais, Renée; Frémont, Pierre; Rossignol, Michel; Stock, Susan R.; Larocque, Isabelle

2005-01-01

Background Tools for early identification of workers with back pain who are at high risk of adverse occupational outcome would help concentrate clinical attention on the patients who need it most, while helping reduce unnecessary interventions (and costs) among the others. This study was conducted to develop and validate clinical rules to predict the 2-year work disability status of people consulting for nonspecific back pain in primary care settings. Methods This was a 2-year prospective cohort study conducted in 7 primary care settings in the Quebec City area. The study enrolled 1007 workers (participation, 68.4% of potential participants expected to be eligible) aged 18–64 years who consulted for nonspecific back pain associated with at least 1 day's absence from work. The majority (86%) completed 5 telephone interviews documenting a large array of variables. Clinical information was abstracted from the medical files. The outcome measure was “return to work in good health” at 2 years, a variable that combined patients' occupational status, functional limitations and recurrences of work absence. Predictive models of 2-year outcome were developed with a recursive partitioning approach on a 40% random sample of our study subjects, then validated on the rest. Results The best predictive model included 7 baseline variables (patient's recovery expectations, radiating pain, previous back surgery, pain intensity, frequent change of position because of back pain, irritability and bad temper, and difficulty sleeping) and was particularly efficient at identifying patients with no adverse occupational outcome (negative predictive value 78%– 94%). Interpretation A clinical prediction rule accurately identified a large proportion of workers with back pain consulting in a primary care setting who were at a low risk of an adverse occupational outcome. PMID:15939915

[THE SIGNIFICANCE OF THE LEGAL PERSPECTIVE - THE LEGAL WORLD'S CONTRIBUTION TO THE MEDICAL WORLD].

PubMed

Sigler-Harcavi, Alona; Cohen Ashkenazi, Limor

2018-04-01

Working with medical and paramedical teams has taught us that the medical staff does not fully utilize the potential of judicial decisions and precedents as a source for learning, drawing conclusions and motivating progress. Judicial ruling is an essential part of the toolbox used by medical administrators in general, and healthcare risk managers in particular. Knowing the relevant legal rulings, before you embark on any given path, is the equivalent of looking before you leap. This is not necessarily an issue of "holy scripture", but should mainly be considered as a source for expanding your perspective. Knowledge of the relevant rulings has many advantages that stem from the unique characteristics of the legal system. While the medical world has a clear and unequivocal advantage regarding knowledge and experience with respect to medicine, the legal world has various other advantages: a different and wider perspective with respect to economic and/or political considerations; universal fundamental principles, such as autonomy, equality, distributive justice, human dignity, the state's obligations to its citizens; complex systems of checks and balances, such as: desirable vs. available, the benefit of few vs. the good of the many, etc. These tools, typical of the legal world, are especially relevant to medicolegal issues, usually associated with medical administration, such as: the obligation of consultation, obligation of follow-up, treatment continuity, priorities, resource distribution, patient rights, etc. The contribution of the legal world to these issues is both unique and essential. Those who question the ability of judges to understand the medical world and to materially contribute to medical thinking and practice, claiming that they lack medical training and experience, should recognize the diverse contribution of the legal world to the medical world.

Efficacy of site-independent telemedicine in the STRokE DOC trial: a randomised, blinded, prospective study

PubMed Central

Meyer, Brett C.; Raman, Rema; Hemmen, Thomas; Obler, Richard; Zivin, Justin A.; Rao, Ramesh; Thomas, Ronald G.; Lyden, Patrick D.

2009-01-01

Background To increase effective use of rt-PA for acute stroke, vascular neurology expertise must be disseminated more widely. We prospectively assessed whether telemedicine (real-time, 2 way audio/video and DICOM interpretation) or telephone was superior for decision-making in acute telemedicine consultations. Methods Acute stroke patients were randomized to telemedicine or telephone consultation. Primary outcome measure was whether the thrombolytic treatment decision was correct, as determined by central adjudication. Secondary outcomes included rt-PA use-rate, 90 day functional outcomes, hemorrhages, and technical observations. Findings Two hundred thirty-four patients were prospectively evaluated. Mean NIHSS score was 9.5 (11.4±8.7 telemedicine, 7.7±7.0 telephone; p=0.0020). One telemedicine consult (0.9%) was aborted for technical reasons, though was included in intention-to-treat analyses. Correct treatment decision was made more often in telemedicine (98.2% telemedicine, 82% telephone; OR 10.9; 95%CI 2.7-44.6; p=0.0009). IV rt-PA use-rate was 25% (28% telemedicine, 23% telephone; OR 1.3; 95%CI 0.7-2.5; p=0.4248). Ninety day functional outcomes were not different for BI(95–100) (OR 0.6; 95%CI 0.4-1.1; p=0.1268) or for mRS (OR 0.6; 95%CI 0.3-1.1; p=0.0898). There was no mortality difference (OR 1.6; 95%CI 0.8-3.4; p=0.2690). Post-rt-PA ICH rates were not different (7% telemedicine, 8% telephone; OR 0.8; 95%CI 0.1-6.3; p=1.0). There was a difference noted for amount of non-completed data (3.1% telemedicine, 12.0% telephone; OR 0.2; 95%CI 0.1-0.3; p<0.001). Interpretation This trial reports that stroke telemedicine consultations result in more accurate decision making, compared to telephone, and can serve as a model for the effective use of telemedicine in other medical fields. The more appropriate decisions, high rt-PA userates, improved data collection, low ICH rates, low technical complications, and favorable time requirements all support telemedicine’s efficacy, most specifically for decision-making, and may enable more practitioners to use telemedicine in daily stroke care. PMID:18676180

DoIT Right: Measuring Effectiveness of Different eConsultation Designs

NASA Astrophysics Data System (ADS)

Grönlund, Åke; Åström, Joachim

eConsultations have been used in many countries over many years, yet most research in the field is case descriptions and there is so far little systematic evidence as to the effectiveness of consultations as a tool for enhancing democracy. Using a case survey method we investigate what factors make a consultation succeed or fail based on data from 57 cases reported in the literature. Success is measured as high participation, deliberative mode of discussion, and impact on policy. We test three hypotheses from the literature claiming, respectively, that institutional design, democratic intent, and quality of research are the most important factors behind the reported success. We find support for all hypotheses. Using consultation at the analysis/decision making stage, mixing online and offline methods and active strategic recruiting are institutional factors positively contributing. Democratic intent and content analysis research both have positive influence.

Causes and remedies for the dominant risk factors in Enterprise System implementation projects: the consultants' perspective.

PubMed

Lech, Przemysław

2016-01-01

The purpose of this research was to investigate the causes of the dominant risk factors, affecting Enterprise System implementation projects and propose remedies for those risk factors from the perspective of implementation consultants. The study used a qualitative research strategy, based on e-mail interviews, semi-structured personal interviews with consultants and participant observation during implementation projects. The main contribution of this paper is that it offers viable indications of how to mitigate the dominant risk factors. These indications were grouped into the following categories: stable project scope, smooth communication supported by the project management, dedicated, competent and decision-making client team, competent and engaged consultant project manager, schedule and budget consistent with the project scope, use of methodology and procedures, enforced and enabled by the project managers, competent and dedicated consultants. A detailed description is provided for each category.

Patients' reflections on communication in the second-opinion hematology-oncology consultation.

PubMed

Goldman, Roberta E; Sullivan, Amy; Back, Anthony L; Alexander, Stewart C; Matsuyama, Robin K; Lee, Stephanie J

2009-07-01

The nature of communication between patients and their second-opinion hematology consultants may be very different in these one-time consultations than for those that are within long-term relationships. This study explored patients' perceptions of their second-opinion hematology-oncology consultation to investigate physician-patient communication in malignant disease at a critical juncture in cancer patients' care and decision-making. In-depth telephone interviews with a subset of 20 patients from a larger study, following their subspecialty hematology consultations. Most patients wanted to contribute to the consultation agenda, but were unable to do so. Patients sought expert and honest advice delivered with empathy, though most did not expect the consultant to directly address their emotions. They wanted the physician to apply his/her knowledge to the specifics of their individual cases, and were disappointed and distrustful when physicians cited only general prognostic statistics. In contrast, physicians' consideration of the unique elements of patients' cases, and demonstrations of empathy and respect made patients' feel positively about the encounter, regardless of the prognosis. Patients provided concrete recommendations for physician and patient behaviors to enhance the consultation. Consideration of these recommendations may result in more effective communication and increased patient satisfaction with medical visits.

Consultation for Simple Laceration Repair When On-Call in the Emergency Department: Potential Quagmire.

PubMed

Zbar, Ross I S; Monico, Edward; Calise, Arthur

2017-07-01

What are the forces obligating a plastic surgeon who is on-call for the emergency department to respond to a consultation request for repair of a simple laceration? Although the duties are clear in cases of obvious surgical emergency, ambiguity and subsequent conflict may arise when the true nature of the emergency is less clear. Does the consultant's clinical discretion dictate the obligation in the case of a simple laceration; or is it subservient to either the discretion of the requesting health-care provider or even the patient? Do federal statutes such as the Emergency Medical Treatment and Labor Act, or perhaps more local rules apply, such as the by-laws of the hospital? It would behoove all medical practitioners to familiarize themselves with both the legal and moral implications of these issues. Having legitimate policies in place which actively address those situations where the consultative obligation is unclear is critical to resolve potential conflict.

Cooperation and Defection in Ghetto

NASA Astrophysics Data System (ADS)

Kułakowski, Krzysztof

We consider ghetto as a community of people ruled against their will by an external power. Members of the community feel that their laws are broken. However, attempts to leave ghetto makes their situation worse. We discuss the relation of the ghetto inhabitants to the ruling power in context of their needs, organized according to the Maslow hierarchy. Decisions how to satisfy successive needs are undertaken in cooperation with or defection the ruling power. This issue allows to construct the tree of decisions and to adopt the pruning technique from the game theory. Dynamics of decisions can be described within the formalism of fundamental equations. The result is that the strategy of defection is stabilized by the estimated payoff.

Feasibility of Providing Web-Based Information to Breast Cancer Patients Prior to a Surgical Consult.

PubMed

Bruce, Jordan G; Tucholka, Jennifer L; Steffens, Nicole M; Mahoney, Jane E; Neuman, Heather B

2017-03-30

Patients facing decisions for breast cancer surgery commonly search the internet. Directing patients to high-quality websites prior to the surgeon consultation may be one way of supporting patients' informational needs. The objective was to test an approach for delivering web-based information to breast cancer patients. The implementation strategy was developed using the Replicating Effective Programs framework. Pilot testing measured the proportion that accepted the web-based information. A pre-consultation survey assessed whether the information was reviewed and the acceptability to stakeholders. Reasons for declining guided refinement to the implementation package. Eighty-two percent (309/377) accepted the web-based information. Of the 309 that accepted, 244 completed the pre-consultation survey. Participants were a median 59 years, white (98%), and highly educated (>50% with a college degree). Most patients who completed the questionnaire reported reviewing the website (85%), and nearly all found it helpful. Surgeons thought implementation increased visit efficiency (5/6) and would result in patients making more informed decisions (6/6). The most common reasons patients declined information were limited internet comfort or access (n = 36), emotional distress (n = 14), and preference to receive information directly from the surgeon (n = 7). Routine delivery of web-based information to breast cancer patients prior to the surgeon consultation is feasible. High stakeholder acceptability combined with the low implementation burden means that these findings have immediate relevance for improving care quality.

10 CFR 1706.5 - General rules.

Code of Federal Regulations, 2011 CFR

2011-01-01

... contract is likely to diminish the contractor's capacity to give impartial assistance and advice, or... activities or research related to the Board's oversight of defense nuclear facilities, where the award would... consulting or other contractual arrangements with other persons or entities, the result of which could give...

10 CFR 1706.5 - General rules.

Code of Federal Regulations, 2010 CFR

2010-01-01

... contract is likely to diminish the contractor's capacity to give impartial assistance and advice, or... activities or research related to the Board's oversight of defense nuclear facilities, where the award would... consulting or other contractual arrangements with other persons or entities, the result of which could give...

Sideline coverage: when to get radiographs? A review of clinical decision tools.

PubMed

Gould, Sara J; Cardone, Dennis A; Munyak, John; Underwood, Philipp J; Gould, Stephen A

2014-05-01

Sidelines coverage presents unique challenges in the evaluation of injured athletes. Health care providers may be confronted with the question of when to obtain radiographs following an injury. Given that most sidelines coverage occurs outside the elite level, radiographs are not readily available at the time of injury, and the decision of when to send a player for radiographs must be made based on physical examination. Clinical tools have been developed to aid in identifying injuries that are likely to result in radiographically important fractures or dislocations. A search for the keywords x-ray and decision rule along with the anatomic locations shoulder, elbow, wrist, knee, and ankle was performed using the PubMed database. No limits were set regarding year of publication. We selected meta-analyses, randomized controlled trials, and survey results. Our selection focused on the largest, most well-studied published reports. We also attempted to include studies that reported the application of the rules to the field of sports medicine. Retrospective literature review. Level 4. The Ottawa Foot and Ankle Rules have been validated and implemented and are appropriate for use in both pediatric and adult populations. The Ottawa Knee Rules have been widely studied, validated, and accepted for evaluation of knee injuries. There are promising studies of decision rules for clinically important fractures of the wrist, but these studies have not been validated. The elbow has been evaluated with good outcomes via the elbow extension test, which has been validated in both single and multicenter studies. Currently, there are no reliable clinical decision tools for traumatic sports injuries to the shoulder to aid in the decision of when to obtain radiographs. Clinical decision tools have been developed to aid in the diagnosis and management of injuries commonly sustained during sporting events. Tools that have been appropriately validated in populations outside the initial study population can assist sports medicine physicians in the decision of when to get radiographs from the sidelines.

An overview of the role of society and risk in xenotransplantation.

PubMed

Sobbrio, Paola; Jorqui, María

2014-01-01

Over time, the notion of public has evolved. While the concept of public was initially conceived of as a single undifferentiated entity, the common understanding is now that a variety of differentiated, multifaceted and multiple public(s) can be constructed for different purposes. This is equally true in xenotransplantation; the literature shows how different kind of publics can be introduced as relevant. The paper explores the notion of public and the contemporary participatory procedures as participatory rights for citizens in decisions concerning technoscience and society. Its perspective, thus, is normative; namely, it aims at understanding how the political role of citizens is changing in democratic societies where matters of innovation are concerned. It is focused on xenotransplantation whose connections with public discourse and practices are quite paradigmatic among new emerging biomedical technologies, due to its peculiar risks. The paper reviews the historical background of risk communication and public involvement in science-based decision-making and provides an overview of the current roles and meanings of deliberative procedures in xenotransplantation. After a short discussion of the history of the social implementation of xenotransplantation, the construction of the different publics dealing with this biomedical technology is briefly analysed. Publics have been firstly conceived of as objects of research, which has looked at them to quantify people's positive and negative attitudes towards xenotransplantation. Further developments have led to the notion of the public as composed of citizens, empowered as subjects of decisions. In both Canadian and Australian consultations, citizens were engaged in a complex learning process aimed at committing them to a decision. Despite the fact both public consultations represented important forms of experimental democracy, they were still focused on seeking consensus and assessing compliance from citizens. New Zealand is the most recent example of public consultation in xenotransplantation. Likewise, several public consultations have recently been launched by the European Commission on Advanced Therapies. Unlike in the Canadian and Australian cases, the latter initiatives aimed to reach only certain parts of the population, and the overall consultations were prepared to seek approval. Several categories of individuals may be interesting and interested publics in xenotransplantation. This is a field in which the importance of the potential risks that xenotransplants pose to society has been widely discussed. The point is that publics should not only be educated about the risk but should be given an opportunity to participate actively in the decision about whether and under what conditions they are exposed to the risk. Likewise, the boundaries between surveys, consultations and collection of advice may be blurred in actual practices. The hope remains that all different instruments either to collect or disseminate knowledge, and to explore new tools of governance may help connect science and policy to society in deeper and more complex ways. The next step points to a different meaning of public participation. It is shifting from participation as mere consensus and risk acceptance, to public engagement as a form of shared responsibility for risk control and regulatory decision-making. © 2014 John Wiley & Sons A/S Published by John Wiley & Sons Ltd.

Shared Decision-Making in the Management of Congenital Vascular Malformations.

PubMed

Horbach, Sophie E R; Ubbink, Dirk T; Stubenrouch, Fabienne E; Koelemay, Mark J W; van der Vleuten, Carine J M; Verhoeven, Bas H; Reekers, Jim A; Schultze Kool, Leo J; van der Horst, Chantal M A M

2017-03-01

In shared decision-making, clinicians and patients arrive at a joint treatment decision, by incorporating best available evidence and the patients' personal values and preferences. Little is known about the role of shared decision-making in managing patients with congenital vascular malformations, for which preference-sensitive decision-making seems obvious. The authors investigated preferences regarding decision-making and current shared decision-making behavior during physician-patient encounters. In two Dutch university hospitals, adults and children with congenital vascular malformations facing a treatment-related decision were enrolled. Before the consultation, patients (or parents of children) expressed their preference regarding decision-making (Control Preferences Scale). Afterward, participants completed shared decision-making-specific questionnaires (nine-item Shared Decision-Making Questionnaire, CollaboRATE, and satisfaction), and physicians completed the Shared Decision-Making Questionnaire-Physician questionnaire. Consultations were audiotaped and patient involvement was scored by two independent researchers using the five-item Observing Patient Involvement instrument. All questionnaire results were expressed on a scale of 0 to 100 (optimum shared decision-making). Fifty-five participants (24 parents and 31 adult patients) were included. Two-thirds preferred the shared decision-making approach (Control Preferences Scale). Objective five-item Observing Patient Involvement scores were low (mean ± SD, 31 ± 15), whereas patient and physician Shared Decision-Making Questionnaire scores were high, with means of 68 ± 18 and 68 ± 19, respectively. The median CollaboRATE score was 93. There was no clear relationship between shared decision-making and satisfaction scores. Although adults and parents of children with vascular malformations express a strong desire for shared decision-making, objective shared decision-making behavior is still lacking, most likely because of poor awareness of the shared decision-making concept among patients, parents, and physicians. To improve shared decision-making practice, targeted interventions (e.g., decision aids, staff training) are essential.

Advanced practice physiotherapy-led triage in Irish orthopaedic and rheumatology services: national data audit.

PubMed

Fennelly, Orna; Blake, Catherine; FitzGerald, Oliver; Breen, Roisin; Ashton, Jennifer; Brennan, Aisling; Caffrey, Aoife; Desmeules, François; Cunningham, Caitriona

2018-06-01

Many people with musculoskeletal (MSK) disorders wait several months or years for Consultant Doctor appointments, despite often not requiring medical or surgical interventions. To allow earlier patient access to orthopaedic and rheumatology services in Ireland, Advanced Practice Physiotherapists (APPs) were introduced at 16 major acute hospitals. This study performed the first national evaluation of APP triage services. Throughout 2014, APPs (n = 22) entered clinical data on a national database. Analysis of these data using descriptive statistics determined patient wait times, Consultant Doctor involvement in clinical decisions, and patient clinical outcomes. Chi square tests were used to compare patient clinical outcomes across orthopaedic and rheumatology clinics. A pilot study at one site identified re-referral rates to orthopaedic/rheumatology services of patients managed by the APPs. In one year, 13,981 new patients accessed specialist orthopaedic and rheumatology consultations via the APP. Median wait time for an appointment was 5.6 months. Patients most commonly presented with knee (23%), lower back (22%) and shoulder (15%) disorders. APPs made autonomous clinical decisions regarding patient management at 77% of appointments, and managed patient care pathways without onward referral to Consultant Doctors in more than 80% of cases. Other onward clinical pathways recommended by APPs were: physiotherapy referrals (42%); clinical investigations (29%); injections administered (4%); and surgical listing (2%). Of those managed by the APP, the pilot study identified that only 6.5% of patients were re-referred within one year. This national evaluation of APP services demonstrated that the majority of patients assessed by an APP did not require onward referral for a Consultant Doctor appointment. Therefore, patients gained earlier access to orthopaedic and rheumatology consultations in secondary care, with most patients conservatively managed.

Lifestyle, health and the ethics of good living. Health behaviour counselling in general practice.

PubMed

Walseth, Liv Tveit; Abildsnes, Eirik; Schei, Edvin

2011-05-01

To present theory that illustrates the relevance of ethics for lifestyle counselling in patient-centred general practice, and to illustrate the theory by a qualitative study exploring how doctors may obstruct or enhance the possibilities for ethical dialogue. The theoretical part is based on theory of common morality and Habermas' communication theory. The empirical study consists of 12 consultations concerning lifestyle changes, followed by interviews of doctors and patients. Identification of two contrasting consultations holding much and little ethical dialogue, "translation" into speech acts, and interpretation of speech acts and interviews guided by theory. General advice obstructed possibilities for ethical clarification and patient-centredness. Ethical clarification was asked for, and was enhanced by the doctor using communication techniques such as interpretation, summarization, and exploration of the objective, subjective and social dimensions of the patients' lifeworlds. However, to produce concrete good decisions an additional reflection over possibilities and obstacles in the patient's lifeworld is necessary. Consultations concerning lifestyle changes hold opportunities for ethical clarification and reflection which may create decisions rooted in the patient's everyday life. The study suggests that GPs should encourage active reflection and deliberation on values and norms in consultations concerning lifestyle changes. Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.

4 CFR 22.4 - Appeal File [Rule 4].

Code of Federal Regulations, 2010 CFR

2010-01-01

... contracting officer relied in making the decision, and any correspondence relating thereto; (v) Transcripts of... 4 Accounts 1 2010-01-01 2010-01-01 false Appeal File [Rule 4]. 22.4 Section 22.4 Accounts... consisting of all documents pertinent to the appeal, including: (i) The decision from which the appeal is...

29 CFR 18.103 - Rulings on evidence.

Code of Federal Regulations, 2010 CFR

2010-07-01

... is more probably true than not true that the error did not materially contribute to the decision or... if explicitly not relied upon by the judge in support of the decision or order. (b) Record of offer... making of an offer in question and answer form. (c) Plain error. Nothing in this rule precludes taking...

34 CFR 31.8 - Rules of decision.

Code of Federal Regulations, 2010 CFR

2010-07-01

... 34 Education 1 2010-07-01 2010-07-01 false Rules of decision. 31.8 Section 31.8 Education Office of the Secretary, Department of Education SALARY OFFSET FOR FEDERAL EMPLOYEES WHO ARE INDEBTED TO THE.... (3) The act or omission of an institution of higher education at which the employee was enrolled does...

Student Expression: The Uncertain Future

ERIC Educational Resources Information Center

Bathon, Justin M.; McCarthy, Martha M.

2008-01-01

On June 25, 2007, the United States Supreme Court rendered its decision in "Morse v. Frederick", a long-awaited ruling regarding student speech in public schools. For nearly twenty years, the Supreme Court had been silent on the issue while lower courts attempted to apply the rules announced in previous Supreme Court decisions. It is…

Use of implicit persuasion in decision making about adjuvant cancer treatment: A potential barrier to shared decision making.

PubMed

Engelhardt, Ellen G; Pieterse, Arwen H; van der Hout, Anja; de Haes, Hanneke J C J M; Kroep, Judith R; Quarles van Ufford-Mannesse, Patricia; Portielje, Johanneke E A; Smets, Ellen M A; Stiggelbout, Anne M

2016-10-01

Shared decision making (SDM) is widely advocated, especially for preference-sensitive decisions like those on adjuvant treatment for early-stage cancer. Here, decision making involves a subjective trade-off between benefits and side-effects, and therefore, patients' informed preferences should be taken into account. If clinicians consciously or unconsciously steer patients towards the option they think is in their patients' best interest (i.e. implicit persuasion), they may be unwittingly subverting their own efforts to implement SDM. We assessed the frequency of use of implicit persuasion during consultations and whether the use of implicit persuasion was associated with expected treatment benefit and/or decision making. Observational study design in which consecutive consultations about adjuvant systemic therapy with stage I-II breast cancer patients treated at oncology outpatient clinics of general teaching hospitals and university medical centres were audiotaped, transcribed and coded by two researchers independently. In total, 105 patients (median age = 59; range: 35-87 years) were included. A median of five (range: 2-10) implicitly persuasive behaviours were employed per consultation. The number of behaviours used did not differ by disease stage (P = 0.07), but did differ by treatment option presented (P = 0.002) and nodal status (P = 0.01). About 50% of patients with stage I or node-negative disease were steered towards undergoing chemotherapy, whereas 96% of patients were steered towards undergoing endocrine therapy, irrespective of expected treatment benefit. Decisions were less often postponed if more implicit persuasion was used (P = 0.03). Oncologists frequently use implicit persuasion, steering patients towards the treatment option that they think is in their patients' best interest. Expected treatment benefit does not always seem to be the driving force behind implicit persuasion. Awareness of one's use of these steering behaviours during decision making is a first step to help overcome the performance gap between advocating and implementing SDM. Copyright © 2016 Elsevier Ltd. All rights reserved.

Individual versus Household Migration Decision Rules: Gender and Marital Status Differences in Intentions to Migrate in South Africa.

PubMed

Gubhaju, Bina; De Jong, Gordon F

2009-03-01

This research tests the thesis that the neoclassical micro-economic and the new household economic theoretical assumptions on migration decision-making rules are segmented by gender, marital status, and time frame of intention to migrate. Comparative tests of both theories within the same study design are relatively rare. Utilizing data from the Causes of Migration in South Africa national migration survey, we analyze how individually held "own-future" versus alternative "household well-being" migration decision rules effect the intentions to migrate of male and female adults in South Africa. Results from the gender and marital status specific logistic regressions models show consistent support for the different gender-marital status decision rule thesis. Specifically, the "maximizing one's own future" neoclassical microeconomic theory proposition is more applicable for never married men and women, the "maximizing household income" proposition for married men with short-term migration intentions, and the "reduce household risk" proposition for longer time horizon migration intentions of married men and women. Results provide new evidence on the way household strategies and individual goals jointly affect intentions to move or stay.

Ventral striatum and the evaluation of memory retrieval strategies.

PubMed

Badre, David; Lebrecht, Sophie; Pagliaccio, David; Long, Nicole M; Scimeca, Jason M

2014-09-01

Adaptive memory retrieval requires mechanisms of cognitive control that facilitate the recovery of goal-relevant information. Frontoparietal systems are known to support control of memory retrieval. However, the mechanisms by which the brain acquires, evaluates, and adapts retrieval strategies remain unknown. Here, we provide evidence that ventral striatal activation tracks the success of a retrieval strategy and correlates with subsequent reliance on that strategy. Human participants were scanned with fMRI while performing a lexical decision task. A rule was provided that indicated the likely semantic category of a target word given the category of a preceding prime. Reliance on the rule improved decision-making, as estimated within a drift diffusion framework. Ventral striatal activation tracked the benefit that relying on the rule had on decision-making. Moreover, activation in ventral striatum correlated with a participant's subsequent reliance on the rule. Taken together, these results support a role for ventral striatum in learning and evaluating declarative retrieval strategies.

77 FR 10651 - How We Collect and Consider Evidence of Disability

Federal Register 2010, 2011, 2012, 2013, 2014

2012-02-23

... determination or decision on your claim. Some examples of when we might purchase a consultative examination to... determining how best to obtain this information, we will be able to make a determination or decision on... (CE) instead. These commenters speculated that some adjudicators may even purchase CEs to undermine...

Pleasure and Pain: Faculty and Administrators in a Shared Governance Environment.

ERIC Educational Resources Information Center

Fitzgerald, Sallyanne H.

1998-01-01

Describes frictions inherent in the decision-making process at a California community college, where shared governance is both clearly defined and mandated. Discusses responsibility versus consultation and offers two successful examples (regarding the writing center and the basic writing program) in which faculty were involved in the decision and…

Child Custody Evaluations: A Rational Process for an Emotion-Laden Event.

ERIC Educational Resources Information Center

Barnard, Charles P.; Jenson, Gust, III

1984-01-01

Presents a consultation model that can serve to diminish the destructive impact of the adversarial process in child custody decisions. The process and procedures described are consonant with what most state statutes suggest as criteria for consideration in custody decisions and promote the best interests of the children. (JAC)

An Analysis of the EPA Report on Pipeline Renewal Decision Making Tools and Approaches

EPA Science Inventory

Few DSS are commercially available for technology selection as most utilities make decisions based on in-house and consultant expertise (Matthews et al., 2011). This review presents some of the models proposed over the past 15 years for selecting technologies in the U.S. and wor...

Teaching points-do they occur and what do they contain? An observation study concerning the general practice rotation.

PubMed

Duncan, Gertrude Florence; Roth, Lisa Marie; Donner-Banzhoff, Nobert; Boesner, Stefan

2016-04-18

A general practice rotation is mandatory in most undergraduate medical education programs. However, little is known about the student-teacher interaction which takes place in this setting. In this study we analyzed occurrence and content of teaching points. From April to December 2012, 410 individual patient consultations were observed in twelve teaching practices associated with the Philipps University Marburg, Germany. Material was collected using structured field-note forms and videotaping. Data analysis was descriptive in form. A teaching point is defined here as a general rule or specific, case-related information divulged by the teaching practitioner. According to the analysis of 410 consultations, teaching points were made in 66.3% of consultations. During these consultations, 74.3% general- and 46.3% case related teaching points occurred; multiple categorizations were possible. Of seven possible topics, therapy was most common, followed, in frequency of occurrence, by patient history, diagnostic procedure, physical examination, disease pathology, differential diagnosis, risk factors and case presentation. The majority of consultations conducted within student presence contained teaching points, most frequently concerning therapy. General teaching points were more common than specific teaching points. Whilst it is encouraging that most consultations included teaching points, faculty development aimed at raising awareness for teaching and learning techniques is important.

Nationwide survey to evaluate the decision-making process in euthanasia requests in Belgium: do specifically trained 2nd physicians improve quality of consultation?

PubMed Central

2014-01-01

Background Following the 2002 enactment of the Belgian law on euthanasia, which requires the consultation of an independent second physician before proceeding with euthanasia, the Life End Information Forum (LEIF) was founded which provides specifically trained physicians who can act as mandatory consultants in euthanasia requests. This study assesses quality of consultations in Flanders and Brussels and compares these between LEIF and non-LEIF consultants. Methods A questionnaire was sent in 2009 to a random sample of 3,006 physicians in Belgium from specialties likely involved in the care of dying patients. Several questions about the last euthanasia request of one of their patients were asked. As LEIF serves the Flemish speaking community (i.e. region of Flanders and the bilingual Brussels Capital Region) and no similar counterpart is present in Wallonia, analyses were limited to Flemish speaking physicians in Flanders and Brussels. Results Response was 34%. Of the 244 physicians who indicated having received a euthanasia request seventy percent consulted a second physician in their last request; in 30% this was with a LEIF physician. Compared to non-LEIF physicians, LEIF physicians were more often not a colleague (69% vs 42%) and not a co-attending physician (89% vs 66%). They tended to more often discuss the request with the attending physician (100% vs 95%) and with the family (76% vs 69%), and also more frequently helped the attending physician with performing euthanasia (44% vs 24%). No significant differences were found in the extent to which they talked to the patient (96% vs 93%) and examined the patient file (94% vs 97%). Conclusion In cases of explicit euthanasia requests in Belgium, the consultation procedure of another physician by the attending physician is not optimal and can be improved. Training and putting at disposal consultants through forums such as LEIF seems able to improve this situation. Adding stipulations in the law about the necessary competencies and tasks of consulting physicians may additionally incite improvement. Irrespective of whether euthanasia is a legal practice within a country, similar services may prove useful to also improve quality of consultations in various other difficult end-of-life decision-making situations. PMID:25030375

Combined rule extraction and feature elimination in supervised classification.

PubMed

Liu, Sheng; Patel, Ronak Y; Daga, Pankaj R; Liu, Haining; Fu, Gang; Doerksen, Robert J; Chen, Yixin; Wilkins, Dawn E

2012-09-01

There are a vast number of biology related research problems involving a combination of multiple sources of data to achieve a better understanding of the underlying problems. It is important to select and interpret the most important information from these sources. Thus it will be beneficial to have a good algorithm to simultaneously extract rules and select features for better interpretation of the predictive model. We propose an efficient algorithm, Combined Rule Extraction and Feature Elimination (CRF), based on 1-norm regularized random forests. CRF simultaneously extracts a small number of rules generated by random forests and selects important features. We applied CRF to several drug activity prediction and microarray data sets. CRF is capable of producing performance comparable with state-of-the-art prediction algorithms using a small number of decision rules. Some of the decision rules are biologically significant.

Prediction of vesicoureteral reflux after a first febrile urinary tract infection in children: validation of a clinical decision rule.

PubMed

Leroy, S; Marc, E; Adamsbaum, C; Gendrel, D; Bréart, G; Chalumeau, M

2006-03-01

To test the reproducibility of a highly sensitive clinical decision rule proposed to predict vesicoureteral reflux (VUR) after a first febrile urinary tract infection in children. This rule combines clinical (family history of uropathology, male gender, young age), biological (raised C reactive protein), and radiological (urinary tract dilation on renal ultrasound) predictors in a score, and provides 100% sensitivity. A retrospective hospital based cohort study included all children, 1 month to 4 years old, with a first febrile urinary tract infection. The sensitivities and specificities of the rule at the two previously proposed score thresholds (< or =0 and < or =5) to predict respectively, all-grade or grade > or =3 VUR, were calculated. A total of 149 children were included. VUR prevalence was 25%. The rule yielded 100% sensitivity and 3% specificity for all-grade VUR, and 93% sensitivity and 13% specificity for grade > or =3 VUR. Some methodological weaknesses explain this lack of reproducibility. The reproducibility of the previously proposed decision rule was poor and its potential contribution to clinical management of children with febrile urinary tract infection seems to be modest.

Prediction of vesicoureteral reflux after a first febrile urinary tract infection in children: validation of a clinical decision rule

PubMed Central

Leroy, S; Marc, E; Adamsbaum, C; Gendrel, D; Bréart, G; Chalumeau, M

2006-01-01

Aims To test the reproducibility of a highly sensitive clinical decision rule proposed to predict vesicoureteral reflux (VUR) after a first febrile urinary tract infection in children. This rule combines clinical (family history of uropathology, male gender, young age), biological (raised C reactive protein), and radiological (urinary tract dilation on renal ultrasound) predictors in a score, and provides 100% sensitivity. Methods A retrospective hospital based cohort study included all children, 1 month to 4 years old, with a first febrile urinary tract infection. The sensitivities and specificities of the rule at the two previously proposed score thresholds (⩽0 and ⩽5) to predict respectively, all‐grade or grade ⩾3 VUR, were calculated. Results A total of 149 children were included. VUR prevalence was 25%. The rule yielded 100% sensitivity and 3% specificity for all‐grade VUR, and 93% sensitivity and 13% specificity for grade ⩾3 VUR. Some methodological weaknesses explain this lack of reproducibility. Conclusions The reproducibility of the previously proposed decision rule was poor and its potential contribution to clinical management of children with febrile urinary tract infection seems to be modest. PMID:15890693

Age differences in understanding precedent-setting decisions and authorities' responses to violations of deontic rules.

PubMed

Klaczynski, Paul A

2011-05-01

To examine age trends in precedent-setting decisions and the effects of these decisions on perceptions of authorities, preadolescents and adolescents were presented with deontic rule infractions that occurred in the absence or presence of mitigating circumstances. In Study 1, in the absence of mitigating circumstances, adolescents recommended punishing rule violations more than preadolescents; when mitigating circumstances were present, adolescents recommended punishing infractions less than preadolescents. In Study 2, before and after receiving information that authorities had punished or permitted rule violations, participants indicated their beliefs in authority legitimacy, rule strength, and rule deterrence value. In the absence of mitigating circumstances, beliefs strengthened when infractions were punished and beliefs weakened when infractions were permitted. When mitigating circumstances were present and authorities punished violations, preadolescents' legitimacy and deterrence beliefs strengthened. Adolescents' deterrence beliefs strengthened, but their beliefs in authority legitimacy weakened. When justifiable infractions were permitted, preadolescents' legitimacy and deterrence beliefs weakened, whereas adolescents' beliefs strengthened. Discussion focuses on age differences in legitimacy beliefs and understanding the consequences of setting precedents and on the relevance of the findings to theories of deontic reasoning, moral judgments, and epistemological development. Copyright © 2010 Elsevier Inc. All rights reserved.

A prospective observational study to assess the diagnostic accuracy of clinical decision rules for children presenting to emergency departments after head injuries (protocol): the Australasian Paediatric Head Injury Rules Study (APHIRST).

PubMed

Babl, Franz E; Lyttle, Mark D; Bressan, Silvia; Borland, Meredith; Phillips, Natalie; Kochar, Amit; Dalziel, Stuart R; Dalton, Sarah; Cheek, John A; Furyk, Jeremy; Gilhotra, Yuri; Neutze, Jocelyn; Ward, Brenton; Donath, Susan; Jachno, Kim; Crowe, Louise; Williams, Amanda; Oakley, Ed

2014-06-13

Head injuries in children are responsible for a large number of emergency department visits. Failure to identify a clinically significant intracranial injury in a timely fashion may result in long term neurodisability and death. Whilst cranial computed tomography (CT) provides rapid and definitive identification of intracranial injuries, it is resource intensive and associated with radiation induced cancer. Evidence based head injury clinical decision rules have been derived to aid physicians in identifying patients at risk of having a clinically significant intracranial injury. Three rules have been identified as being of high quality and accuracy: the Canadian Assessment of Tomography for Childhood Head Injury (CATCH) from Canada, the Children's Head Injury Algorithm for the Prediction of Important Clinical Events (CHALICE) from the UK, and the prediction rule for the identification of children at very low risk of clinically important traumatic brain injury developed by the Pediatric Emergency Care Applied Research Network (PECARN) from the USA. This study aims to prospectively validate and compare the performance accuracy of these three clinical decision rules when applied outside the derivation setting. This study is a prospective observational study of children aged 0 to less than 18 years presenting to 10 emergency departments within the Paediatric Research in Emergency Departments International Collaborative (PREDICT) research network in Australia and New Zealand after head injuries of any severity. Predictor variables identified in CATCH, CHALICE and PECARN clinical decision rules will be collected. Patients will be managed as per the treating clinicians at the participating hospitals. All patients not undergoing cranial CT will receive a follow up call 14 to 90 days after the injury. Outcome data collected will include results of cranial CTs (if performed) and details of admission, intubation, neurosurgery and death. The performance accuracy of each of the rules will be assessed using rule specific outcomes and inclusion and exclusion criteria. This study will allow the simultaneous comparative application and validation of three major paediatric head injury clinical decision rules outside their derivation setting. The study is registered with the Australian New Zealand Clinical Trials Registry (ANZCTR)- ACTRN12614000463673 (registered 2 May 2014).

Evaluation of decision rules for identifying low bone density in postmenopausal African-American women.

PubMed Central

Wallace, Lorraine Silver; Ballard, Joyce E.; Holiday, David; Turner, Lori W.; Keenum, Amy J.; Pearman, Cynthia M.

2004-01-01

OBJECTIVE: While African-American women tend to have greater bone mineral density (BMD) than caucasian women, they are still at risk of developing osteoporosis later in life. Clinical decision rules (i.e., algorithms) have been developed to assist clinicians identify women at greatest risk of low BMD. However, such tools have only been validated in caucasian and Asian populations. Accordingly, the objective of this study was to compare the performance of five clinical decision rules in identifying postmenopausal African-American women at greatest risk for low femoral BMD. METHODOLOGY: One hundred-seventy-four (n=174) postmenopausal African-American women completed a valid and reliable oral questionnaire to assess lifestyle characteristics, and completed height and weight measures. BMD at the femoral neck was measured via dual energy x-ray absorptiometry (DXA). We calculated sensitivity, specificity, positive predictive value, and negative predictive value for identifying African-American women with low BMD (T-Score < or = -2.0 SD) using five clinical decision rules: Age, Body Size, No Estrogen (ABONE), Osteoporosis Risk Assessment Instrument (ORAI), Osteoporosis Self-Assessment Tool (OST), Simple Calculated Osteoporosis Risk Estimation (SCORE), and body weight less than 70 kg. RESULTS: Approximately 30% of African-American women had low BMD, half of whom had osteoporosis (BMD T-Score < or = -2.5 SD). Sensitivity for identifying women with a low BMD (T-Score < or = -2.0 SD) ranged from 65.57-83.61%, while specificity ranged from 53.85-78.85%. Positive predictive values ranged from 80.95-87.91%, while negative predictive values ranged from 48.44-58.33%. CONCLUSION: Our data suggest that the clinical decision rules analyzed in this study have some usefulness for identifying postmenopausal African-American women with low BMD. However, there is a need to establish cut-points for these clinical decision rules in a larger, more diverse sample of African-American women. PMID:15040510

Heuristics: foundations for a novel approach to medical decision making.

PubMed

Bodemer, Nicolai; Hanoch, Yaniv; Katsikopoulos, Konstantinos V

2015-03-01

Medical decision-making is a complex process that often takes place during uncertainty, that is, when knowledge, time, and resources are limited. How can we ensure good decisions? We present research on heuristics-simple rules of thumb-and discuss how medical decision-making can benefit from these tools. We challenge the common view that heuristics are only second-best solutions by showing that they can be more accurate, faster, and easier to apply in comparison to more complex strategies. Using the example of fast-and-frugal decision trees, we illustrate how heuristics can be studied and implemented in the medical context. Finally, we suggest how a heuristic-friendly culture supports the study and application of heuristics as complementary strategies to existing decision rules.

Development and acceptability testing of decision trees for self-management of prosthetic socket fit in adults with lower limb amputation.

PubMed

Lee, Daniel Joseph; Veneri, Diana A

2018-05-01

The most common complaint lower limb prosthesis users report is inadequacy of a proper socket fit. Adjustments to the residual limb-socket interface can be made by the prosthesis user without consultation of a clinician in many scenarios through skilled self-management. Decision trees guide prosthesis wearers through the self-management process, empowering them to rectify fit issues, or referring them to a clinician when necessary. This study examines the development and acceptability testing of patient-centered decision trees for lower limb prosthesis users. Decision trees underwent a four-stage process: literature review and expert consultation, designing, two-rounds of expert panel review and revisions, and target audience testing. Fifteen lower limb prosthesis users (average age 61 years) reviewed the decision trees and completed an acceptability questionnaire. Participants reported agreement of 80% or above in five of the eight questions related to acceptability of the decision trees. Disagreement was related to the level of experience of the respondent. Decision trees were found to be easy to use, illustrate correct solutions to common issues, and have terminology consistent with that of a new prosthesis user. Some users with greater than 1.5 years of experience would not use the decision trees based on their own self-management skills. Implications for Rehabilitation Discomfort of the residual limb-prosthetic socket interface is the most common reason for clinician visits. Prosthesis users can use decision trees to guide them through the process of obtaining a proper socket fit independently. Newer users may benefit from using the decision trees more than experienced users.

A study to derive a clinical decision rule for triage of emergency department patients with chest pain: design and methodology

PubMed Central

Hess, Erik P; Wells, George A; Jaffe, Allan; Stiell, Ian G

2008-01-01

Background Chest pain is the second most common chief complaint in North American emergency departments. Data from the U.S. suggest that 2.1% of patients with acute myocardial infarction and 2.3% of patients with unstable angina are misdiagnosed, with slightly higher rates reported in a recent Canadian study (4.6% and 6.4%, respectively). Information obtained from the history, 12-lead ECG, and a single set of cardiac enzymes is unable to identify patients who are safe for early discharge with sufficient sensitivity. The 2007 ACC/AHA guidelines for UA/NSTEMI do not identify patients at low risk for adverse cardiac events who can be safely discharged without provocative testing. As a result large numbers of low risk patients are triaged to chest pain observation units and undergo provocative testing, at significant cost to the healthcare system. Clinical decision rules use clinical findings (history, physical exam, test results) to suggest a diagnostic or therapeutic course of action. Currently no methodologically robust clinical decision rule identifies patients safe for early discharge. Methods/design The goal of this study is to derive a clinical decision rule which will allow emergency physicians to accurately identify patients with chest pain who are safe for early discharge. The study will utilize a prospective cohort design. Standardized clinical variables will be collected on all patients at least 25 years of age complaining of chest pain prior to provocative testing. Variables strongly associated with the composite outcome acute myocardial infarction, revascularization, or death will be further analyzed with multivariable analysis to derive the clinical rule. Specific aims are to: i) apply standardized clinical assessments to patients with chest pain, incorporating results of early cardiac testing; ii) determine the inter-observer reliability of the clinical information; iii) determine the statistical association between the clinical findings and the composite outcome; and iv) use multivariable analysis to derive a highly sensitive clinical decision rule to guide triage decisions. Discussion The study will derive a highly sensitive clinical decision rule to identify low risk patients safe for early discharge. This will improve patient care, lower healthcare costs, and enhance flow in our busy and overcrowded emergency departments. PMID:18254973

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

PubMed

Stephens, Ashley L; Heitman, Elizabeth

2015-01-01

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

What Ethical Issues Really Arise in Practice at an Academic Medical Center? A Quantitative and Qualitative Analysis of Clinical Ethics Consultations from 2008 to 2013.

PubMed

Wasson, Katherine; Anderson, Emily; Hagstrom, Erika; McCarthy, Michael; Parsi, Kayhan; Kuczewski, Mark

2016-09-01

As the field of clinical ethics consultation sets standards and moves forward with the Quality Attestation process, questions should be raised about what ethical issues really do arise in practice. There is limited data on the type and number of ethics consultations conducted across different settings. At Loyola University Medical Center, we conducted a retrospective review of our ethics consultations from 2008 through 2013. One hundred fifty-six cases met the eligibility criteria. We analyzed demographic data on these patients and conducted a content analysis of the ethics consultation write-ups coding both the frequency of ethical issues and most significant, or key, ethical issue per case. Patients for whom ethics consultation was requested were typically male (55.8 %), white (57.1 %), between 50 and 69 years old (38.5 %), of non-Hispanic origin (85.9 %), and of Roman Catholic faith (43.6 %). Nearly half (47.4 %) were in the intensive care unit and 44.2 % died in the hospital. The most frequent broad ethical categories were decision-making (93.6 %), goals of care/treatment (80.8 %), and end-of-life (73.1 %). More specifically, capacity (57.1 %), patient's wishes/autonomy (54.5 %), and surrogate decision maker (51.3 %) were the most frequent particular ethical issues. The most common key ethical issues were withdrawing/withholding treatment (12.8 %), patient wishes/autonomy (12.2 %), and capacity (11.5 %). Our findings provide additional data to inform the training of clinical ethics consultants regarding the ethical issues that arise in practice. A wider research agenda should be formed to collect and compare data across institutions to improve education and training in our field.

Pre-consultation educational group intervention to improve shared decision-making in postmastectomy breast reconstruction: study protocol for a pilot randomized controlled trial.

PubMed

Platt, Jennica; Baxter, Nancy; Jones, Jennifer; Metcalfe, Kelly; Causarano, Natalie; Hofer, Stefan O P; O'Neill, Anne; Cheng, Terry; Starenkyj, Elizabeth; Zhong, Toni

2013-07-06

The Pre-Consultation Educational Group INTERVENTION pilot study seeks to assess the feasibility and inform the optimal design for a definitive randomized controlled trial that aims to improve the quality of decision-making in postmastectomy breast reconstruction patients. This is a mixed-methods pilot feasibility randomized controlled trial that will follow a single-center, 1:1 allocation, two-arm parallel group superiority design. The University Health Network, a tertiary care cancer center in Toronto, Canada. Adult women referred to one of three plastic and reconstructive surgeons for delayed breast reconstruction or prophylactic mastectomy with immediate breast reconstruction. We designed a multi-disciplinary educational group workshop that incorporates the key components of shared decision-making, decision-support, and psychosocial support for cancer survivors prior to the initial surgical consult. The intervention consists of didactic lectures by a plastic surgeon and nurse specialist on breast reconstruction choices, pre- and postoperative care; a value-clarification exercise led by a social worker; and discussions with a breast reconstruction patient. Usual care includes access to an informational booklet, website, and patient volunteer if desired. Expected pilot outcomes include feasibility, recruitment, and retention targets. Acceptability of intervention and full trial outcomes will be established through qualitative interviews. Trial outcomes will include decision-quality measures, patient-reported outcomes, and service outcomes, and the treatment effect estimate and variability will be used to inform the sample size calculation for a full trial. Our pilot study seeks to identify the (1) feasibility, acceptability, and design of a definitive RCT and (2) the optimal content and delivery of our proposed educational group intervention. Thirty patients have been recruited to date (8 April 2013), of whom 15 have been randomized to one of three decision support workshops. The trial will close as planned in May 2013. NCT01857882.

75 FR 56019 - Domestic Dates Produced or Packed in Riverside County, CA; Increased Assessment Rate

Federal Register 2010, 2011, 2012, 2013, 2014

2010-09-15

... nutritional research, and $14,225 for marketing and media consulting. The budgeted amount for promotional..., $97,000 for promotional programs, $15,000 for nutritional research, and $28,000 for marketing and..., September 15, 2010 / Proposed Rules#0;#0; [[Page 56019

48 CFR 9.508 - Examples.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 48 Federal Acquisition Regulations System 1 2010-10-01 2010-10-01 false Examples. 9.508 Section 9... CONTRACTOR QUALIFICATIONS Organizational and Consultant Conflicts of Interest 9.508 Examples. The examples in... officer apply the general rules in 9.505 to individual contract situations. (a) Company A agrees to...

Costs can influence family planning decisions.

PubMed

Barnett, B

1998-01-01

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

Distributed decision making in action: diagnostic imaging investigations within the bigger picture.

PubMed

Makanjee, Chandra R; Bergh, Anne-Marie; Hoffmann, Willem A

2018-03-01

Decision making in the health care system - specifically with regard to diagnostic imaging investigations - occurs at multiple levels. Professional role players from various backgrounds are involved in making these decisions, from the point of referral to the outcomes of the imaging investigation. The aim of this study was to map the decision-making processes and pathways involved when patients are referred for diagnostic imaging investigations and to explore distributed decision-making events at the points of contact with patients within a health care system. A two-phased qualitative study was conducted in an academic public health complex with the district hospital as entry point. The first phase included case studies of 24 conveniently selected patients, and the second phase involved 12 focus group interviews with health care providers. Data analysis was based on Rapley's interpretation of decision making as being distributed across time, situations and actions, and including different role players and technologies. Clinical decisions incorporating imaging investigations are distributed across the three vital points of contact or decision-making events, namely the initial patient consultation, the diagnostic imaging investigation and the post-investigation consultation. Each of these decision-making events is made up of a sequence of discrete decision-making moments based on the transfer of retrospective, current and prospective information and its transformation into knowledge. This paper contributes to the understanding of the microstructural processes (the 'when' and 'where') involved in the distribution of decisions related to imaging investigations. It also highlights the interdependency in decision-making events of medical and non-medical providers within a single medical encounter. © 2017 The Authors. Journal of Medical Radiation Sciences published by John Wiley & Sons Australia, Ltd on behalf of Australian Society of Medical Imaging and Radiation Therapy and New Zealand Institute of Medical Radiation Technology.