Faggion, Clovis Mariano; Pachur, Thorsten; Giannakopoulos, Nikolaos Nikitas
Shared decision-making involves the participation of patient and dental practitioner. Well-informed decision-making requires that both parties understand important concepts that may influence the decision. This fourth article in a series of 4 aims to discuss the importance of patients' values when a clinical decision is made. We report on how to incorporate important concepts for well-informed, shared decision-making. Here, we present patient values as an important issue, in addition to previously established topics such as the risk of bias of a study, cost-effectiveness of treatment approaches, and a comparison of therapeutic benefit with potential side effects. We provide 2 clinical examples and suggestions for a decision tree, based on the available evidence. The information reported in this article may improve the relationship between patient and dental practitioner, resulting in more well-informed clinical decisions. Copyright © 2017 Elsevier Inc. All rights reserved.
Ursu, Samuel C.
Discussion of legal issues in dental clinical decision making looks at the nature and elements of applicable law, especially malpractice, locus of responsibility, and standards of care. Greater use of formal decision analysis in clinical dentistry and better research on diagnosis and treatment are recommended, particularly in light of increasing…
Hess, Søren; Bjerring, Ole Steen; Pfeiffer, Per
and initial stages. This article outlines the potential use of fluorodeoxyglucose-PET/CT in clinical decision making with special regard to preoperative evaluation and response assessment in gastric cancer (including the gastroesophageal junction), pancreatic cancer (excluding neuroendocrine tumors...
Aim The aim of this study is to develop an understanding of the factors which influence veterinary surgeons’ clinical decision making during routine consultations. Methods The research takes a qualitative approach using video-cued interviews, in which one of the veterinary surgeon’s own consultations is used as the basis of a semi-structured interview exploring decision making in real cases. The research focuses primarily on small animal consultations in first opinion practice, how...
Crebbin, Wendy; Beasley, Spencer W; Watters, David A K
Clinical decision making is a core competency of surgical practice. It involves two distinct types of mental process best considered as the ends of a continuum, ranging from intuitive and subconscious to analytical and conscious. In practice, individual decisions are usually reached by a combination of each, according to the complexity of the situation and the experience/expertise of the surgeon. An expert moves effortlessly along this continuum, according to need, able to apply learned rules or algorithms to specific presentations, choosing these as a result of either pattern recognition or analytical thinking. The expert recognizes and responds quickly to any mismatch between what is observed and what was expected, coping with gaps in information and making decisions even where critical data may be uncertain or unknown. Even for experts, the cognitive processes involved are difficult to articulate as they tend to be very complex. However, if surgeons are to assist trainees in developing their decision-making skills, the processes need to be identified and defined, and the competency needs to be measurable. This paper examines the processes of clinical decision making in three contexts: making a decision about how to manage a patient; preparing for an operative procedure; and reviewing progress during an operative procedure. The models represented here are an exploration of the complexity of the processes, designed to assist surgeons understand how expert clinical decision making occurs and to highlight the challenge of teaching these skills to surgical trainees. © 2013 The Authors. ANZ Journal of Surgery © 2013 Royal Australasian College of Surgeons.
Walker, Paul; Lovat, Terry
This paper is predicated on the understanding that clinical encounters between clinicians and patients should be seen primarily as inter-relations among persons and, as such, are necessarily moral encounters. It aims to relocate the discussion to be had in challenging medical decision-making situations, including, for example, as the end of life comes into view, onto a more robust moral philosophical footing than is currently commonplace. In our contemporary era, those making moral decisions must be cognizant of the existence of perspectives other than their own, and be attuned to the demands of inter-subjectivity. Applicable to clinical practice, we propose and justify a Habermasian approach as one useful means of achieving what can be described as dialogic consensus. The Habermasian approach builds around, first, his discourse theory of morality as universalizable to all and, second, communicative action as a cooperative search for truth. It is a concrete way to ground the discourse which must be held in complex medical decision-making situations, in its actual reality. Considerations about the theoretical underpinnings of the application of dialogic consensus to clinical practice, and potential difficulties, are explored.
Nurses' clinical decision-making is a complex process that holds potential to influence the quality of care provided and patient outcomes. The evolution of nurses' decision-making that occurs with experience has been well documented. In addition, literature includes numerous strategies and approaches purported to support development of nurses' clinical decision-making. There has been, however, significantly less attention given to the process of assessing nurses' clinical decision-making and novice clinical educators are often challenged with knowing how to best support nurses and nursing students in developing their clinical decision-making capacity. The Situated Clinical Decision-Making framework is presented for use by clinical educators: it provides a structured approach to analyzing nursing students' and novice nurses' decision-making in clinical nursing practice, assists educators in identifying specific issues within nurses' clinical decision-making, and guides selection of relevant strategies to support development of clinical decision-making. A series of questions is offered as a guide for clinical educators when assessing nurses' clinical decision-making. The discussion presents key considerations related to analysis of various decision-making components, including common sources of challenge and errors that may occur within nurses' clinical decision-making. An exemplar illustrates use of the framework and guiding questions. Implications of this approach for selection of strategies that support development of clinical decision-making are highlighted. Copyright © 2010 Elsevier Ltd. All rights reserved.
Fowler, M D
Contemporary nursing ethics education focuses on the use of an analytical model of ethical decision making for both its process and its content. Perhaps this is the case because it bears some resemblance to the nursing process, which is taught in a similar fashion. Thus, a deductivist method of ethical decision making fits within the same general schema of the hypotheticodeductive method of decision making that is taught for nursing diagnosis. Ethics requires that nurses respect persons, inform patients and secure their consent, not inflict harm, preserve the patient's quality of life, prevent harm and remove harmful conditions, do good for patients, and minimize risk to themselves. These are among the norms of obligation that guide ethical analysis and judgment in nursing practice and are the substance of the analytical model of ethical decision making. Nursing's ethics has established high ideals and strong demands for nurses. These are demands which nurses have met and ideals which have often been realized. Whatever the strength of our science, nursing is an inherently moral endeavor and is only as strong as its commitment to its ethical obligations and values. Between the grinding edges of the forces that affect it, nursing must establish its priorities among the aspects of its environment that it attempts to control. Ethics must be chief among those priorities.
Ida Torunn Bjørk; Glenys A. Hamilton
This study analyzed nurses' perceptions of clinical decision making (CDM) in their clinical practice and compared differences in decision making related to nurse demographic and contextual variables. A cross-sectional survey was carried out with 2095 nurses in four hospitals in Norway. A 24-item Nursing Decision Making Instrument based on cognitive continuum theory was used to explore how nurses perceived their CDM when meeting an elective patient for the first time. Data were analyzed with d...
As a feedback mechanism to promote or improve the quality of clinical decisions in nursing, standards for quality clinical decision-making are proposed in an exemplary manner. In addition, a system for quality clinical decisionmaking in nursing capitalises on the heritage of the nursing process. Considering the changes and ...
Full Text Available Abstract Background Shared decision-making has been advocated; however there are relatively few studies on physician preferences for, and experiences of, different styles of clinical decision-making as most research has focused on patient preferences and experiences. The objectives of this study were to determine 1 physician preferences for different styles of clinical decision-making; 2 styles of clinical decision-making physicians perceive themselves as practicing; and 3 the congruence between preferred and perceived style. In addition we sought to determine physician perceptions of the availability of time in visits, and their role in encouraging patients to look for health information. Methods Cross-sectional survey of a nationally representative sample of U.S. physicians. Results 1,050 (53% response rate physicians responded to the survey. Of these, 780 (75% preferred to share decision-making with their patients, 142 (14% preferred paternalism, and 118 (11% preferred consumerism. 87% of physicians perceived themselves as practicing their preferred style. Physicians who preferred their patients to play an active role in decision-making were more likely to report encouraging patients to look for information, and to report having enough time in visits. Conclusion Physicians tend to perceive themselves as practicing their preferred role in clinical decision-making. The direction of the association cannot be inferred from these data; however, we suggest that interventions aimed at promoting shared decision-making need to target physicians as well as patients.
Mental health (MH) triage is a specialist area of clinical nursing practice that involves complex decision making. The discussion in this article draws on the findings of a Ph.D. study that involved a statewide investigation of the scope of MH triage nursing practice in Victoria, Australia. Although the original Ph.D. study investigated a number of core practices in MH triage, the focus of the discussion in this article is specifically on the findings related to clinical decision making in MH triage, which have not previously been published. The study employed an exploratory descriptive research design that used mixed data collection methods including a survey questionnaire (n = 139) and semistructured interviews (n = 21). The study findings related to decision making revealed a lack of empirically tested evidence-based decision-making frameworks currently in use to support MH triage nursing practice. MH triage clinicians in Australia rely heavily on clinical experience to underpin decision making and have little of knowledge of theoretical models for practice, such as methodologies for rating urgency. A key recommendation arising from the study is the need to develop evidence-based decision-making frameworks such as clinical guidelines to inform and support MH triage clinical decision making.
Woda, Aimee; Hansen, Jamie; Paquette, Mary; Topp, Robert
An emerging nursing education trend is to utilize simulated learning experiences as a means to optimize competency and decision making skills. The purpose of this study was to examine differences in students' perception of clinical decision making and clinical decision making-related self-confidence and anxiety based on the sequence (order) in which they participated in a block of simulated versus hospital-based learning experiences. A quasi-experimental crossover design was used. Between and within group differences were found relative to self-confidence with the decision making process. When comparing groups, at baseline the simulation followed by hospital group had significantly higher self-confidence scores, however, at 14-weeks both groups were not significantly different. Significant within group differences were found in the simulation followed by hospital group only, demonstrating a significant decrease in clinical decision making related anxiety across the semester. Finally, there were no significant difference in; perceived clinical decision making within or between the groups at the two measurement points. Preliminary findings suggest that simulated learning experiences can be offered with alternating sequences without impacting the process, anxiety or confidence with clinical decision making. This study provides beginning evidence to guide curriculum development and allow flexibility based on student needs and available resources. Copyright © 2017. Published by Elsevier Ltd.
Peeters, Suzanne Y G; Hoek, Amber E; Mollink, Susan M; Huff, J Stephen
Syncope is a common occurrence in the emergency department, accounting for approximately 1% to 3% of presentations. Syncope is best defined as a brief loss of consciousness and postural tone followed by spontaneous and complete recovery. The spectrum of etiologies ranges from benign to life threatening, and a structured approach to evaluating these patients is key to providing care that is thorough, yet cost-effective. This issue reviews the most relevant evidence for managing and risk stratifying the syncope patient, beginning with a focused history, physical examination, electrocardiogram, and tailored diagnostic testing. Several risk stratification decision rules are compared for performance in various scenarios, including how age and associated comorbidities may predict short-term and long-term adverse events. An algorithm for structured, evidence-based care of the syncope patient is included to ensure that patients requiring hospitalization are managed appropriately and those with benign causes are discharged safely.
Dunphy, Bruce C.; Cantwell, Robert; Bourke, Sid; Fleming, Mark; Smith, Bruce; Joseph, K. S.; Dunphy, Stacey L
Physician cognition, metacognition and affect may have an impact upon the quality of clinical reasoning. The purpose of this study was to examine the relationship between measures of physician metacognition and affect and patient outcomes in obstetric practice. Reflective coping (RC), proactive coping, need for cognition (NFC), tolerance for…
Trimble, Michael; Hamilton, Paul
Diagnostic errors are responsible for a significant number of adverse events. Logical reasoning and good decision-making skills are key factors in reducing such errors, but little emphasis has traditionally been placed on how these thought processes occur, and how errors could be minimised. In this article, we explore key cognitive ideas that underpin clinical decision making and suggest that by employing some simple strategies, physicians might be better able to understand how they make decisions and how the process might be optimised. © 2016 Royal College of Physicians.
Cioffi, J; Markham, R
In making clinical judgements, it is argued that midwives use 'shortcuts' or heuristics based on estimated probabilities to simplify the decision-making task. Midwives (n = 30) were given simulated patient assessment situations of high and low complexity and were required to think aloud. Analysis of verbal protocols showed that subjective probability judgements (heuristics) were used more frequently in the high than low complexity case and predominated in the last quarter of the assessment period for the high complexity case. 'Representativeness' was identified more frequently in the high than in the low case, but was the dominant heuristic in both. Reports completed after each simulation suggest that heuristics based on memory for particular conditions affect decisions. It is concluded that midwives use heuristics, derived mainly from their clinical experiences, in an attempt to save cognitive effort and to facilitate reasonably accurate decisions in the decision-making process.
Calder, Lisa A; Forster, Alan J; Stiell, Ian G; Carr, Laura K; Brehaut, Jamie C; Perry, Jeffrey J; Vaillancourt, Christian; Croskerry, Patrick
Dual-process psychological theories argue that clinical decision making is achieved through a combination of experiential (fast and intuitive) and rational (slower and systematic) cognitive processes. To determine whether emergency physicians perceived their clinical decisions in general to be more experiential or rational and how this compared with other physicians. A validated psychometric tool, the Rational Experiential Inventory (REI-40), was sent through postal mail to all emergency physicians registered with the College of Physicians and Surgeons of Ontario, according to their website in November 2009. Forty statements were ranked on a Likert scale from 1 (Definitely False) to 5 (Definitely True). An initial survey was sent out, followed by reminder cards and a second survey to non-respondents. Analysis included descriptive statistics, Student t tests, analysis of variance and comparison of mean scores with those of cardiologists from New Zealand. The response rate in this study was 46.9% (434/925). The respondents' median age was 41-50 years; they were mostly men (72.6%) and most had more than 10 years of clinical experience (66.8%). The mean REI-40 rational scores were higher than the experiential scores (3.93/5 (SD 0.35) vs 3.33/5 (SD 0.49), prational 3.93/5, mean experiential 3.05/5). The mean experiential scores were significantly higher for female respondents than for male respondents (3.40/5 (SD 0.49) vs 3.30/5 (SD 0.48), p=0.003). Overall, emergency physicians favoured rational decision making rather than experiential decision making; however, female emergency physicians had higher experiential scores than male emergency physicians. This has important implications for future knowledge translation and decision support efforts among emergency physicians.
Marcum, James A
What role, if any, should emotions play in clinical reasoning and decision making? Traditionally, emotions have been excluded from clinical reasoning and decision making, but with recent advances in cognitive neuropsychology they are now considered an important component of them. Today, cognition is thought to be a set of complex processes relying on multiple types of intelligences. The role of mathematical logic (hypothetico-deductive thinking) or verbal linguistic intelligence in cognition, for example, is well documented and accepted; however, the role of emotional intelligence has received less attention-especially because its nature and function are not well understood. In this paper, I argue for the inclusion of emotions in clinical reasoning and decision making. To that end, developments in contemporary cognitive neuropsychology are initially examined and analyzed, followed by a review of the medical literature discussing the role of emotions in clinical practice. Next, a published clinical case is reconstructed and used to illustrate the recognition and regulation of emotions played during a series of clinical consultations, which resulted in a positive medical outcome. The paper's main thesis is that emotions, particularly in terms of emotional intelligence as a practical form of intelligence, afford clinical practitioners a robust cognitive resource for providing quality medical care.
Barfoed, Benedicte Marie Lind
Objectives We aim to present new knowledge about different perspectives of health care professionals’ risk perceptions and clinical decision making. Furthermore, we intend to discuss differences between professional and personal risk perceptions and the impact on decisions in terms of both short...... and long-term outcomes. Background Insight into healthcare professionals’ perception of risk is a cornerstone for understanding their strategies for practising preventive care. The way people perceive risk can be seen as part of a general personality trait influenced by a mixture of individual...... considerations and the specific context. Most research has been focused on understanding of the concepts of risk. However healthcare professionals’ risk perception and personal attitudes also affect their clinical decision-making and risk communication. The differences between health care professionals’ personal...
Epstein, Ronald Mark
To review the theory, research evidence and ethical implications regarding "whole mind" and "shared mind" in clinical practice in the context of chronic and serious illnesses. Selective critical review of the intersection of classical and naturalistic decision-making theories, cognitive neuroscience, communication research and ethics as they apply to decision-making and autonomy. Decision-making involves analytic thinking as well as affect and intuition ("whole mind") and sharing cognitive and affective schemas of two or more individuals ("shared mind"). Social relationships can help processing of complex information that otherwise would overwhelm individuals' cognitive capacities. Medical decision-making research, teaching and practice should consider both analytic and non-analytic cognitive processes. Further, research should consider that decisions emerge not only from the individual perspectives of patients, their families and clinicians, but also the perspectives that emerge from the interactions among them. Social interactions have the potential to enhance individual autonomy, as well as to promote relational autonomy based on shared frames of reference. Shared mind has the potential to result in wiser decisions, greater autonomy and self-determination; yet, clinicians and patients should be vigilant for the potential of hierarchical relationships to foster coercion or silencing of the patient's voice. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.
Ida Torunn Bjørk
Full Text Available This study analyzed nurses' perceptions of clinical decision making (CDM in their clinical practice and compared differences in decision making related to nurse demographic and contextual variables. A cross-sectional survey was carried out with 2095 nurses in four hospitals in Norway. A 24-item Nursing Decision Making Instrument based on cognitive continuum theory was used to explore how nurses perceived their CDM when meeting an elective patient for the first time. Data were analyzed with descriptive frequencies, t-tests, Chi-Square test, and linear regression. Nurses' decision making was categorized into analytic-systematic, intuitive-interpretive, and quasi-rational models of CDM. Most nurses reported the use of quasi-rational models during CDM thereby supporting the tenet that cognition most often includes properties of both analysis and intuition. Increased use of intuitive-interpretive models of CDM was associated with years in present job, further education, male gender, higher age, and working in predominantly surgical units.
Khatry, K; Peel, N M; Gray, L C; Hubbard, R E
Using clinical vignettes, this study aimed to determine if a measure of patient frailty would impact management decisions made by geriatricians regarding commonly encountered clinical situations. Electronic surveys consisting of three vignettes derived from cases commonly seen in an acute inpatient ward were distributed to geriatricians. Vignettes included patients being considered for intensive care treatment, rehabilitation, or coronary artery bypass surgery. A frailty index was generated through Comprehensive electronic Geriatric Assessment. For each vignette, respondents were asked to make a recommendation for management, based on either a brief or detailed amount of clinical information and to reconsider their decision after the addition of the frailty index. The study suggests that quantification of frailty might aid the clinical judgment now employed daily to proceed with usual care, or to modify it based on the vulnerability of the person to whom it is aimed.
Pier Luigi Baldi
Full Text Available This article points out some conditions which significantly exert an influence upon decision and compares decision making and problem solving as interconnected processes. Some strategies of decision making are also examined.
Wulff, H R
An attempt is made to discuss some of the philosophical implications of the use of decision-analytic techniques. The probabilities of a decision analysis are subjective measures of belief, and it is concluded that clinicians base their subjective beliefs on both recorded observations and theoretical knowledge. The clinical decision maker also evaluates the consequences of his actions, and therefore clinical decision theory transcends medical science. A number of different schools of normative ethics are mentioned to illustrate the complexity of everyday decision making. The philosophical terminology is useful for the analysis of clinical problems, and it is argued that clinical decision making has both a teleological and a deontological component. The results of decision-analytic studies depend on such factors as the wealth of the country, the organization of the health service, and cultural norms.
Tenconi, Elena; Degortes, Daniela; Clementi, Maurizio; Collantoni, Enrico; Pinato, Claudia; Forzan, Monica; Cassina, Matteo; Santonastaso, Paolo; Favaro, Angela
Decision-making (DM) abilities have been found to be impaired in anorexia nervosa (AN), but few data are available about the characteristics and correlates of this cognitive function. The aim of the present study was to provide data on DM functioning in AN using both veridical and adaptive paradigms. While in veridical DM tasks, the individual's ability to predict a true/false response is measured, adaptive DM is the ability to consider both internal and external demands in order to make a good choice, in the absence of a single true "correct" answer. The participants were 189 women, of whom 91 were eating-disordered patients with a lifetime diagnosis of anorexia nervosa, and 98 were healthy women. All the participants underwent clinical, neuropsychological, and genetic assessment. The cognitive evaluation included a set of neuropsychological tasks and two decision-making tests: The Iowa Gambling Task and the Cognitive Bias Task. Anorexia nervosa patients showed significantly poorer performances on both decision-making tasks than healthy women. The Cognitive Bias Task revealed that anorexia nervosa patients employed significantly more context-independent decision-making strategies, which were independent from diagnostic subtype, handedness, education, and psychopathology. In the whole sample (patients and controls), Cognitive Bias Task performance was independently predicted by lifetime anorexia nervosa diagnosis, body mass index at assessment, and 5-HTTLPR genotype. Patients displayed poor decision-making functioning in both veridical and adaptive situations. The difficulties detected in anorexia nervosa individuals may affect not only the ability to consider the future outcomes of their actions (leading to "myopia for the future"), but also the capacity to update and review one's own mindset according to new environmental stimuli.
Keefe, Carole W; Thompson, Margaret E; Noel, Mary Margaret
Improving access to preventive care requires addressing patient, provider, and systems barriers. Patients often lack knowledge or are skeptical about the importance of prevention. Physicians feel that they have too little time, are not trained to deliver preventive services, and are concerned about the effectiveness of prevention. We have implemented an educational module in the required family practice clerkship (1) to enhance medical student learning about common clinical preventive services and (2) to teach students how to inform and involve patients in shared decision making about those services. Students are asked to examine available evidence-based information for preventive screening services. They are encouraged to look at the recommendations of various organizations and use such resources as reports from the U.S. Preventive Services Task Force to determine recommendations they want to be knowledgeable about in talking with their patients. For learning shared decision making, students are trained to use a model adapted from Braddock and colleagues(1) to discuss specific screening services and to engage patients in the process of making informed decisions about what is best for their own health. The shared decision making is presented and modeled by faculty, discussed in small groups, and students practice using Web-based cases and simulations. The students are evaluated using formative and summative performance-based assessments as they interact with simulated patients about (1) screening for high blood cholesterol and other lipid abnormalities, (2) screening for colorectal cancer, (3) screening for prostate cancer, and (4) screening for breast cancer. The final student evaluation is a ten-minute, videotaped discussion with a simulated patient about screening for colorectal cancer that is graded against a checklist that focuses primarily on the elements of shared decision making. Our medical students appear quite willing to accept shared decision making as
Seright, T J
Nurses in rural settings are often the first to assess and interpret the patient's clinical presentations. Therefore, an understanding of how nurses experience decision-making is important in terms of educational preparation, resource allocation to rural areas, institutional cultures, and patient outcomes. Theory development was based on the in-depth investigation of 12 novice nurses practicing in rural critical access hospitals in a north central state. This grounded theory study consisted of face-to-face interviews with 12 registered nurses, nine of whom were observed during their work day. The participants were interviewed a second time, as a method of member checking, and during this interview they reviewed their transcripts, the emerging themes and categories. Directors of nursing from both the research sites and rural hospitals not involved in the study, experienced researchers, and nurse educators facilitated triangulation of the findings. 'Sociocentric rationalizing' emerged as the central phenomenon and referred to the sense of belonging and agency which impacted the decision-making in this small group of novice nurses in rural critical access hospitals. The observed consequences, which were conceptualized during the axial coding process and were derived from observations and interviews of the 12 novice nurses in this study include: (1) gathering information before making a decision included assessment of: the credibility of co-workers, patients' subjective and objective data, and one's own past and current experiences; (2) conferring with co-workers as a direct method of confirming/denying decisions being made was considered more realistic and expedient than policy books and decision trees; (3) rural practicum clinical experiences, along with support after orientation, provide for transition to the rural nurse role; (4) involved directors of nursing served as both models and protectors of novice nurses placed in high accountability positions early in
Islam, Roosan; Weir, Charlene; Del Fiol, Guilherme
Clinical decision support is a tool to help experts make optimal and efficient decisions. However, little is known about the high level of abstractions in the thinking process for the experts. The objective of the study is to understand how clinicians manage complexity while dealing with complex clinical decision tasks. After approval from the Institutional Review Board (IRB), three clinical experts were interviewed the transcripts from these interviews were analyzed. We found five broad categories of strategies by experts for managing complex clinical decision tasks: decision conflict, mental projection, decision trade-offs, managing uncertainty and generating rule of thumb. Complexity is created by decision conflicts, mental projection, limited options and treatment uncertainty. Experts cope with complexity in a variety of ways, including using efficient and fast decision strategies to simplify complex decision tasks, mentally simulating outcomes and focusing on only the most relevant information. Understanding complex decision making processes can help design allocation based on the complexity of task for clinical decision support design.
Fischer, T; Brothers, K B; Erdmann, P; Langanke, M
Systems medicine is the name for an assemblage of scientific strategies and practices that include bioinformatics approaches to human biology (especially systems biology); "big data" statistical analysis; and medical informatics tools. Whereas personalized and precision medicine involve similar analytical methods applied to genomic and medical record data, systems medicine draws on these as well as other sources of data. Given this distinction, the clinical translation of systems medicine poses a number of important ethical and epistemological challenges for researchers working to generate systems medicine knowledge and clinicians working to apply it. This article focuses on three key challenges: First, we will discuss the conflicts in decision-making that can arise when healthcare providers committed to principles of experimental medicine or evidence-based medicine encounter individualized recommendations derived from computer algorithms. We will explore in particular whether controlled experiments, such as comparative effectiveness trials, should mediate the translation of systems medicine, or if instead individualized findings generated through "big data" approaches can be applied directly in clinical decision-making. Second, we will examine the case of the Riyadh Intensive Care Program Mortality Prediction Algorithm, pejoratively referred to as the "death computer," to demonstrate the ethical challenges that can arise when big-data-driven scoring systems are applied in clinical contexts. We argue that the uncritical use of predictive clinical algorithms, including those envisioned for systems medicine, challenge basic understandings of the doctor-patient relationship. Third, we will build on the recent discourse on secondary findings in genomics and imaging to draw attention to the important implications of secondary findings derived from the joint analysis of data from diverse sources, including data recorded by patients in an attempt to realize their
Pizzorno, Joseph E
As 21st century health care moves from a disease-based approach to a more patient-centric system that can address biochemical individuality to improve health and function, clinical decision making becomes more complex. Accentuating the problem is the lack of a clear standard for this more complex functional medicine approach. While there is relatively broad agreement in Western medicine for what constitutes competent assessment of disease and identification of related treatment approaches, the complex functional medicine model posits multiple and individualized diagnostic and therapeutic approaches, most or many of which have reasonable underlying science and principles, but which have not been rigorously tested in a research or clinical setting. This has led to non-rigorous thinking and sometimes to uncritical acceptance of both poorly documented diagnostic procedures and ineffective therapies, resulting in less than optimal clinical care.
Gerven, M.A.J. van
This dissertation deals with decision support in the context of clinical oncology. (Dynamic) Bayesian networks are used as a framework for (dynamic) decision-making under uncertainty and applied to a variety of diagnostic, prognostic, and treatment problems in medicine. It is shown that the proposed
Chambers, David W
A decision is a commitment of resources under conditions of risk in expectation of the best future outcome. The smart decision is always the strategy with the best overall expected value-the best combination of facts and values. Some of the special circumstances involved in decision making are discussed, including decisions where there are multiple goals, those where more than one person is involved in making the decision, using trigger points, framing decisions correctly, commitments to lost causes, and expert decision makers. A complex example of deciding about removal of asymptomatic third molars, with and without an EBD search, is discussed.
Brady, Mike; Northstone, Kate
Aims Remote clinical decision-making (RCDM), commonly known as 'telephone triage' or 'hear and treat', describes clinicians' non-face-to-face involvement with patient care, and is an established strategy in UK ambulance services for managing increasing demand. However, there is no suitable definition of RCDM that fully explains the roles undertaken by clinicians in 999 hubs, or for its use as an ambulance quality indicator (AQI). The aim of this study, which is part of a larger evaluation of a new RCDM module in higher education, is to determine how clinicians define RCDM. Methods Three participants were asked, during semi-structured interviews, to define RCDM. The interviews were recorded, transcribed and thematically analysed. Results Clinicians do not focus on outcomes when defining RCDM, but on the efficacy of the process and the appropriateness of the determined outcome. Conclusion There is no precise description of the role of healthcare professionals in 999 clinical hubs, but there is a need for role clarity, for employees and organisations. The study questions the suitability of the definition of hear and treat as an AQI, as it does not appear to represent fully the various duties undertaken by 999 clinical hub healthcare professionals. More research is needed to consider the definition of RCDM in all its forms.
Khong, Peck Chui Betty; Hoi, Shu Yin; Holroyd, Eleanor; Wang, Wenru
Healthcare information technology systems are considered the ideal tool to inculcate evidence-based nursing practices. The wound clinical decision support system was built locally to support nurses to manage pressure ulcer wounds in their daily practice. However, its adoption rate is not optimal. The study's objective was to discover the concepts that informed the RNs' decisions to adopt the wound clinical decision support system as an evidence-based technology in their nursing practice. This was an exploratory, descriptive, and qualitative design using face-to-face interviews, individual interviews, and active participatory observation. A purposive, theoretical sample of 14 RNs was recruited from one of the largest public tertiary hospitals in Singapore after obtaining ethics approval. After consenting, the nurses were interviewed and observed separately. Recruitment stopped when data saturation was reached. All transcribed interview data underwent a concurrent thematic analysis, whereas observational data were content analyzed independently and subsequently triangulated with the interview data. Eight emerging themes were identified, namely, use of the wound clinical decision support system, beliefs in the wound clinical decision support system, influences of the workplace culture, extent of the benefits, professional control over nursing practices, use of knowledge, gut feelings, and emotions (fear, doubt, and frustration). These themes represented the nurses' mental outlook as they made decisions on adopting the wound clinical decision support system in light of the complexities of their roles and workloads. This research has provided insight on the nurses' thoughts regarding their decision to interact with the computer environment in a Singapore context. It captured the nurses' complex thoughts when deciding whether to adopt or reject information technology as they practice in a clinical setting.
Full Text Available Weihua Tang1, Zhiyuan Hu2, Hind Muallem1, Margaret L Gulley1,21Department of Pathology and Laboratory Medicine, 2Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, North Carolina, NC, USAAbstract: RNA profiling is increasingly used to predict drug response, dose, or toxicity based on analysis of drug pharmacokinetic or pharmacodynamic pathways. Before implementing multiplexed RNA arrays in clinical practice, validation studies are carried out to demonstrate sufficient evidence of analytic and clinical performance, and to establish an assay protocol with quality assurance measures. Pathologists assure quality by selecting input tissue and by interpreting results in the context of the input tissue as well as the technologies that were used and the clinical setting in which the test was ordered. A strength of RNA profiling is the array-based measurement of tens to thousands of RNAs at once, including redundant tests for critical analytes or pathways to promote confidence in test results. Instrument and reagent manufacturers are crucial for supplying reliable components of the test system. Strategies for quality assurance include careful attention to RNA preservation and quality checks at pertinent steps in the assay protocol, beginning with specimen collection and proceeding through the various phases of transport, processing, storage, analysis, interpretation, and reporting. Specimen quality is checked by probing housekeeping transcripts, while spiked and exogenous controls serve as a check on analytic performance of the test system. Software is required to manipulate abundant array data and present it for interpretation by a laboratory physician who reports results in a manner facilitating therapeutic decision-making. Maintenance of the assay requires periodic documentation of personnel competency and laboratory proficiency. These strategies are shepherding genomic arrays into clinical settings to provide added
Soria, Angèle; Autegarden, Elodie; Amsler, Emmanuelle; Gaouar, Hafida; Vial, Amandine; Francès, Camille; Autegarden, Jean-Eric
About 10% of subjects report suspected penicillin allergy, but 85-90% of these patients are not truly allergic and could safely receive beta-lactam antibiotics Objective: To design and validate a clinical decision-making algorithm, based on anamnesis (chronology, severity, and duration of the suspected allergic reactions) and reaching a 100% sensitivity and negative predictive value, to assess allergy risk related to a penicillin prescription in general practise. All patients were included prospectively and explorated based on ENDA/EAACI recommendations. Results of penicillin allergy work-up (gold standard) were compared with results of the algorithm. Allergological work-up diagnosed penicillin hypersensitivity in 41/259 patients (15.8%) [95% CI: 11.5-20.3]. Three of these patients were diagnosed as having immediate-type hypersensitivity to penicillin, but had been misdiagnosed as low risk patients using the clinical algorithm. Thus, the sensitivity and negative predictive value of the algorithm were 92.7% [95% CI: 80.1-98.5] and 96.3% [95% CI: 89.6-99.2], respectively, and the probability that a patient with true penicillin allergy had been misclassified was 3.7% [95% CI: 0.8-10.4]. Although the risk of misclassification is low, we cannot recommend the use of this algorithm in general practice. However, the algorithm can be useful in emergency situations in hospital settings. Key messages True penicillin allergy is considerably lower than alleged penicillin allergy (15.8%; 41 of the 259 patients with suspected penicillin allergy). A clinical algorithm based on the patient's clinical history of the supposed allergic event to penicillin misclassified 3/41 (3.7%) truly allergic patients.
Zadik, Yehuda; Levin, Liran
The purpose of this study was to evaluate the influence of geographic location of graduation (Israel, Eastern Europe, Latin America) on decision making regarding management of dental caries, periapical lesions, and antibiotic prescribing routines. A questionnaire was given to ninety-eight general practitioners regarding demographic and work habits. Photographs of lesions were shown on a screen. Participants reported recommended treatment and whether they would routinely prescribe antibiotics following regular endodontic treatment, retreatment, and impacted third molar surgical extraction in healthy patients. There was a 94 percent (n=92) response rate, of which eighty-five responses were used in the data analysis. Surgical treatment of asymptomatic enamel caries lesions was not recommended by most of the subjects, and surgery was recommended for DEJ caries lesions in low or moderate caries risk patients, both without significant differences between geographic regions of dental school graduation. Israelis had a lower frequency of retreatment in asymptomatic teeth that demonstrated periapical radiolucency with post restoration (without crown) compared to Latin Americans and East Europeans. Most of the participants would not retreat asymptomatic teeth that demonstrated periapical radiolucency with post and crown. After third molar surgery, 46 percent of participants routinely prescribed antibiotics. Significantly more Latin American graduates prescribed antibiotics following endodontic treatment, retreatment, and third molar extractions (pantibiotics) and overtreatment (caries) among young practitioners reflect failure of undergraduate education in proper use of antibiotics and management of the carious lesions according to the patient's clinical presentation and caries risk assessment rather than routinely undertaking surgical caries treatment.
Cornuz, Jacques; Junod, Noëlle; Pasche, Olivier; Guessous, Idris
Shared decision-making approach to uncertain clinical situations such as cancer screening seems more appropriate than ever. Shared decision making can be defined as an interactive process where physician and patient share all the stages of the decision making process. For patients who wish to be implicated in the management of their health conditions, physicians might express difficulty to do so. Use of patient decision aids appears to improve such process of shared decision making.
Tabak, N; Bar-Tal, Y; Cohen-Mansfield, J
Decision making is an important daily nursing activity. Given contradictory past findings concerning the ease of use cognitive schema for reaching decisions among experts and novices, we chose to examine consistency of information as a parameter that may clarify the process of decision making. Ninety-two experienced nurses and 65 nursing students rated their decisional difficulty and levels of certainty in reaching a diagnosis for two scenarios: one including consistent information and one providing information that was partly inconsistent with the given diagnosis. For the consistent information, students showed more difficulty and less certainty in the given diagnosis than the experienced nurses. The inconsistent scenario was perceived as more difficult by nurses in comparison to students. The cognitive processes responsible for these results are discussed.
The decision making process is central to the practice of a clinician and has traditionally been described in terms of the hypothetico-deductive model. More recently, models adapted from cognitive psychology, such as the dual process and script theories have proved useful in explaining patterns of practice not consistent with purely cognitive…
Schuitmaker-Warnaar, T.J.; Scheele, Fedde
Shared decision-making (SDM) is promoted as tool for improving quality and responsiveness of care, while lowering overall costs. The underlying idea of SDM is well-conceptualised and a wide range of experiments in the Netherlands and abroad have been executed over the last couple of years. However,
Schroy, Paul C; Caron, Sarah E; Sherman, Bonnie J; Heeren, Timothy C; Battaglia, Tracy A
Shared decision making (SDM) related to test preference has been advocated as a potentially effective strategy for increasing adherence to colorectal cancer (CRC) screening, yet primary care providers (PCPs) are often reluctant to comply with patient preferences if they differ from their own. Risk stratification advanced colorectal neoplasia (ACN) provides a rational strategy for reconciling these differences. To assess the importance of risk stratification in PCP decision making related to test preference for average-risk patients and receptivity to use of an electronic risk assessment tool for ACN to facilitate SDM. Mixed methods, including qualitative key informant interviews and a cross-sectional survey. PCPs at an urban, academic safety-net institution. Screening preferences, factors influencing patient recommendations and receptivity to use of a risk stratification tool. Nine PCPs participated in interviews and 57 completed the survey. Despite an overwhelming preference for colonoscopy by 95% of respondents, patient risk (67%) and patient preferences (63%) were more influential in their decision making than patient comorbidities (31%; P decision making, yet few providers considered risk factors other than age for average-risk patients. Providers were receptive to the use of a risk assessment tool for ACN when recommending an appropriate screening test for select patients. © 2013 John Wiley & Sons Ltd.
Narra, Lekha; Sahama, Tony; Stapleton, Peta
Large volumes of heterogeneous health data silos pose a big challenge when exploring for information to allow for evidence based decision making and ensuring quality outcomes. In this paper, we present a proof of concept for adopting data warehousing technology to aggregate and analyse disparate health data in order to understand the impact various lifestyle factors on obesity. We present a practical model for data warehousing with detailed explanation which can be adopted similarly for studying various other health issues.
Ghana’s slow progress towards attaining millennium development goal 5 has been associated with gaps in quality of care, particularly quality of clinical decision making for clients. This thesis reviews the relevance and effect of clinical decision making support tools on pregnancy outcomes. Relevance of three clinical decision making support tools available to frontline providers of care in the Greater Accra region is discussed. These are routine maternal health service delivery data populati...
Biedrzycki, Barbara A
To describe factors and outcomes related to the decision-making process regarding participation in a cancer clinical trial. Cross-sectional, descriptive. Urban, academic, National Cancer Institute-designated comprehensive cancer center in the mid-Atlantic United States. 197 patients with advanced gastrointestinal cancer. Mailed survey using one investigator-developed instrument, eight instruments used in published research, and a medical record review. disease context, sociodemographics, hope, quality of life, trust in healthcare system, trust in health professional, preference for research decision control, understanding risks, and information. decision to accept or decline research participation and satisfaction with this decision. All of the factors within the Research Decision Making Model together predicted cancer clinical trial participation and satisfaction with this decision. The most frequently preferred decision-making style for research participation was shared (collaborative) (83%). Multiple factors affect decision making for cancer clinical trial participation and satisfaction with this decision. Shared decision making previously was an unrecognized factor and requires further investigation. Enhancing the process of research decision making may facilitate an increase in cancer clinical trial enrollment rates. Oncology nurses have unique opportunities as educators and researchers to support shared decision making by those who prefer this method for deciding whether to accept or decline cancer clinical trial participation.
Cosh, S.; Zentner, N.; Ay, E.; Loos, S.; Slade, Mike; Maj, Mario; Salzano, A.; Berecz, R.; Glaub, T.; Munk-Jørgensen, Povl; Krogsgaard Bording, M.; Rössler, Wulf; Kawohl, Wolfram; Puschner, Bernd
Objective: This study aims to explore relationships between preferred and experienced clinical decision making with service use, and associated costs, by people with severe mental illness.\\ud Methods: Prospective observational study of mental healthcare in six European countries: Germany, UK, Italy Hungary, Denmark and Switzerland. Patients (N = 588) and treating clinicians (N = 213) reported preferred and experienced decision making at baseline using the Clinical Decision Making Style Scale ...
Ghana’s slow progress towards attaining millennium development goal 5 has been associated with gaps in quality of care, particularly quality of clinical decision making for clients. This thesis reviews the relevance and effect of clinical decision making support tools on pregnancy
Doebbeling, Bradley N; Burton, Matthew M; Wiebke, Eric A; Miller, Spencer; Baxter, Laurence; Miller, Donald; Alvarez, Jorge; Pekny, Joseph
Perioperative care is complex and involves multiple interconnected subsystems. Delayed starts, prolonged cases and overtime are common. Surgical procedures account for 40-70% of hospital revenues and 30-40% of total costs. Most planning and scheduling in healthcare is done without modern planning tools, which have potential for improving access by assisting in operations planning support. We identified key planning scenarios of interest to perioperative leaders, in order to examine the feasibility of applying combinatorial optimization software solving some of those planning issues in the operative setting. Perioperative leaders desire a broad range of tools for planning and assessing alternate solutions. Our modeled solutions generated feasible solutions that varied as expected, based on resource and policy assumptions and found better utilization of scarce resources. Combinatorial optimization modeling can effectively evaluate alternatives to support key decisions for planning clinical workflow and improving care efficiency and satisfaction.
Tiffen, Jennifer; Corbridge, Susan J; Slimmer, Lynda
Clinical decision making is a term frequently used to describe the fundamental role of the nurse practitioner; however, other terms have been used interchangeably. The purpose of this article is to begin the process of developing a definition and framework of clinical decision making. The developed definition was "Clinical decision making is a contextual, continuous, and evolving process, where data are gathered, interpreted, and evaluated in order to select an evidence-based choice of action." A contiguous framework for clinical decision making specific for nurse practitioners is also proposed. Having a clear and unique understanding of clinical decision making will allow for consistent use of the term, which is relevant given the changing educational requirements for nurse practitioners and broadening scope of practice. Copyright © 2014 Elsevier Inc. All rights reserved.
Flores, Amanda; Cobos, Pedro L; López, Francisco J; Godoy, Antonio
In an experiment that used the inconsistency paradigm, experienced clinical psychologists and psychology students performed a reading task using clinical reports and a diagnostic judgment task. The clinical reports provided information about the symptoms of hypothetical clients who had been previously diagnosed with a specific mental disorder. Reading times of inconsistent target sentences were slower than those of control sentences, demonstrating an inconsistency effect. The results also showed that experienced clinicians gave different weights to different symptoms according to their relevance when fluently reading the clinical reports provided, despite the fact that all the symptoms were of equal diagnostic value according to the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; American Psychiatric Association, 2000). The diagnostic judgment task yielded a similar pattern of results. In contrast to previous findings, the results of the reading task may be taken as direct evidence of the intervention of reasoning processes that occur very early, rapidly, and online. We suggest that these processes are based on the representation of mental disorders and that these representations are particularly suited to fast retrieval from memory and to making inferences. They may also be related to the clinicians' causal reasoning. The implications of these results for clinician training are also discussed.
Vedsegaard, Helle; Schrader, Anne-Marie; Rom, Gitte
The current study responds to implementation challenges with translating evidence-based knowledge into practice. We explore how appreciative inquiry can be used in in-house learning sessions for nurses to enhance their knowledge in using a guideline on delirium as part of clinical decision making...... and axial coding drawing on the principles of grounded theory. The study shows that appreciative inquiry was meaningful to cardiology nurses in providing them with knowledge of using a guideline on delirium in clinical decision making, the main reasons being a) data on a current patient were included, b....... Through 18 sessions with 3–12 nurses, an appreciative inquiry approach was used. Specialist nurses from the Heart Centre of Copenhagen and senior lecturers from the Department of Nursing at Metropolitan University College facilitated the sessions. Field notes from the sessions were analysed using open...
Fukai, Kakuhiro; Yoshino, Koichi; Ohyama, Atsushi; Takaesu, Yoshinori
In economics, the concept of utility refers to the strength of customer preference. In health care assessment, the visual analogue scale (VAS), the standard gamble, and the time trade-off are used to measure health state utilities. These utility measurements play a key role in promoting shared decision-making in dental care. Individual preference, however, is complex and dynamic. The purpose of this study was to investigate the relationship between patient preference and educational intervention in the field of dental health. The data were collected by distributing questionnaires to employees of two companies in Japan. Participants were aged 18-65 years and consisted of 111 males and 93 females (204 in total). One company (Group A) had a dental program of annual check-ups and health education in the workplace, while the other company (Group B) had no such program. Statistical analyses were performed with the t-test and Chi-square test. The questionnaire items were designed to determine: (1) oral health-related quality of life, (2) dental health state utilities (using VAS), and (3) time trade-off for regular dental check-ups. The percentage of respondents in both groups who were satisfied with chewing function, appearance of teeth, and social function ranged from 23.1 to 42.4%. There were no significant differences between groups A and B in the VAS of decayed, filled, and missing teeth. The VAS of gum bleeding was 42.8 in Group A and 51.3 in Group B (pdecision-making.
Voldbjerg, Siri; Elgaard Sørensen, Erik; Grønkjær, Mette
Clinical-decision-making is of decisive importance to how evidence-based practice is put into practice. Schools of Nursing have a responsibility to teach and train nursing students to make clinical decisions within a frame of evidence-based practice. Clinical decision-making among nurses has been...... explored from numerous angles using a diversity of methodologies. Existing research has mainly focused on promoting and inhibiting factors for implementation of evidence-based practice and incorporation of research evidence in the clinical-decision. Little attention has been given to the nurses' behavior......, including the knowledge that actually informs the newly graduated nurses’ clinical decision. The aim of the study is to combine and synthesize results from qualitative research. Noblit and Hare’s meta-ethnographic approach is used to conduct a metasynthesis of qualitative research that has studied...
Daemers, Darie O A; van Limbeek, Evelien B M; Wijnen, Hennie A A; Nieuwenhuijze, Marianne J; de Vries, Raymond G
Although midwives make clinical decisions that have an impact on the health and well-being of mothers and babies, little is known about how they make those decisions. Wide variation in intrapartum decisions to refer women to obstetrician-led care suggests that midwives' decisions are based on more than the evidence based medicine (EBM) model - i.e. clinical evidence, midwife's expertise, and woman's values - alone. With this study we aimed to explore the factors that influence clinical decision-making of midwives who work independently. We used a qualitative approach, conducting in-depth interviews with a purposive sample of 11 Dutch primary care midwives. Data collection took place between May and September 2015. The interviews were semi-structured, using written vignettes to solicit midwives' clinical decision-making processes (Think Aloud method). We performed thematic analysis on the transcripts. We identified five themes that influenced clinical decision-making: the pregnant woman as a whole person, sources of knowledge, the midwife as a whole person, the collaboration between maternity care professionals, and the organisation of care. Regarding the midwife, her decisions were shaped not only by her experience, intuition, and personal circumstances, but also by her attitudes about physiology, woman-centredness, shared decision-making, and collaboration with other professionals. The nature of the local collaboration between maternity care professionals and locally-developed protocols dominated midwives' clinical decision-making. When midwives and obstetricians had different philosophies of care and different practice styles, their collaborative efforts were challenged. Midwives' clinical decision-making is a more varied and complex process than the EBM framework suggests. If midwives are to succeed in their role as promoters and protectors of physiological pregnancy and birth, they need to understand how clinical decisions in a multidisciplinary context are
Hantula, Donald A.
Clinical applications of statistical process control (SPC) in human service organizations are considered. SPC is seen as providing a standard set of criteria that serves as a common interface for data-based decision making, which may bring decision making under the control of established contingencies rather than the immediate contingencies of…
The daily routine requires complex thinking processes of nurses, but clinical decision making and critical thinking are underestimated in nursing. A great demand for educational measures in clinical judgement related with the diagnostic process was found in nurses. The German literature hardly describes nursing diagnoses as clinical judgements about human reactions on health problems / life processes. Critical thinking is described as an intellectual, disciplined process of active conceptualisation, application and synthesis of information. It is gained through observation, experience, reflection and communication and leads thinking and action. Critical thinking influences the aspects of clinical decision making a) diagnostic judgement, b) therapeutic reasoning and c) ethical decision making. Human reactions are complex processes and in their course, human behavior is interpreted in the focus of health. Therefore, more attention should be given to the nursing diagnostic process. This article presents the theoretical framework of the paper "Clinical decision making: Fostering critical thinking in the nursing diagnostic process through case studies".
Robertson, Eden G; Wakefield, Claire E; Signorelli, Christina; Cohn, Richard J; Patenaude, Andrea; Foster, Claire; Pettit, Tristan; Fardell, Joanna E
We conducted a systematic review to identify the strategies that have been recommended in the literature to facilitate shared decision-making regarding enrolment in pediatric oncology clinical trials. We searched seven databases for peer-reviewed literature, published 1990-2017. Of 924 articles identified, 17 studies were eligible for the review. We assessed study quality using the 'Mixed-Methods Appraisal Tool'. We coded the results and discussions of papers line-by-line using nVivo software. We categorized strategies thematically. Five main themes emerged: 1) decision-making as a process, 2) individuality of the process; 3) information provision, 4) the role of communication, or 5) decision and psychosocial support. Families should have adequate time to make a decision. HCPs should elicit parents' and patients' preferences for level of information and decision involvement. Information should be clear and provided in multiple modalities. Articles also recommended providing training for healthcare professionals and access to psychosocial support for families. High quality, individually-tailored information, open communication and psychosocial support appear vital in supporting decision-making regarding enrollment in clinical trials. These data will usefully inform future decision-making interventions/tools to support families making clinical trial decisions. A solid evidence-base for effective strategies which facilitate shared decision-making is needed. Copyright © 2018 Elsevier B.V. All rights reserved.
Kozlowski, Desirée; Hutchinson, Marie; Hurley, John; Rowley, Joanne; Sutherland, Joanna
Background Traditionally, clinical decision making has been perceived as a purely rational and cognitive process. Recently, a number of authors have linked emotional intelligence (EI) to clinical decision making (CDM) and calls have been made for an increased focus on EI skills for clinicians. The objective of this integrative literature review was to identify and synthesise the empirical evidence for a role of emotion in CDM. Methods A systematic search of the bibliographic databases PubMed,...
Holmes-Rovner, Margaret; Nelson, Wendy L; Pignone, Michael; Elwyn, Glyn; Rovner, David R; O'Connor, Annette M; Coulter, Angela; Correa-de-Araujo, Rosaly
This article reports on the International Patient Decision Aid Standards Symposium held in 2006 at the annual meeting of the Society for Medical Decision Making in Cambridge, Massachusetts. The symposium featured a debate regarding the proposition that "decision aids are the best way to improve clinical decision making.'' The formal debate addressed the theoretical problem of the appropriate gold standard for an improved decision, efficacy of decision aids, and prospects for implementation. Audience comments and questions focused on both theory and practice: the often unacknowledged roots of decision aids in expected utility theory and the practical problems of limited patient decision aid implementation in health care. The participants' vote on the proposition was approximately half for and half against.
Price, Amanda; Zulkosky, Kristen; White, Krista; Pretz, Jean
To assess the reliance on intuitive and analytical approaches during clinical decision-making among novice clinicians and whether that reliance is associated with accurate decision-making. Nurse educators and managers tend to emphasize analysis over intuition during clinical decision-making though nurses typically report some reliance on intuition in their practice. We hypothesized that under certain conditions, reliance on intuition would support accurate decision-making, even among novices. This study utilized an experimental design with clinical complication (familiar vs. novel) and decision phase (cue acquisition, diagnosis and action) as within-subjects' factors, and simulation role (observer, family, auxiliary nurse and primary nurse) as between-subjects' factor. We examined clinical decision-making accuracy among final semester pre-licensure nursing students in a simulation experience. Students recorded their reasoning about emerging clinical complications with their patient during two distinct points in the simulation; one point involved a familiar complication and the other a relatively novel complication. All data were collected during Spring 2015. Although most participants relied more heavily on analysis than on intuition, use of intuition during the familiar complication was associated with more accurate decision-making, particularly in guiding attention to relevant cues. With the novel complication, use of intuition appeared to hamper decision-making, particularly for those in an observer role. Novice clinicians should be supported by educators and nurse managers to note when their intuitions are likely to be valid. Our findings emphasize the integrated nature of intuition and analysis in clinical decision-making. © 2016 John Wiley & Sons Ltd.
Deshpande, Saee; Lambade, Dipti; Chahande, Jayashree
Best practice strategies for helping students learn the reasoning skills of problem solving and critical thinking (CT) remain a source of conjecture, particularly with regard to CT. The dental education literature is fundamentally devoid of research on the cognitive components of clinical decision-making. This study was aimed to develop and evaluate the impact of blended learning module on clinical decision-making skills of dental graduates for planning prosthodontics rehabilitation. An interactive teaching module consisting of didactic lectures on clinical decision-making and a computer-assisted case-based treatment planning software was developed Its impact on cognitive knowledge gain in clinical decision-making was evaluated using an assessment involving problem-based multiple choice questions and paper-based case scenarios. Mean test scores were: Pretest (17 ± 1), posttest 1 (21 ± 2) and posttest 2 (43 ± 3). Comparison of mean scores was done with one-way ANOVA test. There was overall significant difference in between mean scores at all the three points (P posttest 1 > pretest. Blended teaching methods employing didactic lectures on the clinical decision-making as well as computer assisted case-based learning can be used to improve quality of clinical decision-making in prosthodontic rehabilitation for dental graduates.
Hajjaj, F M; Salek, M S; Basra, M K A; Finlay, A Y
This article reviews an aspect of daily clinical practice which is of critical importance in virtually every clinical consultation, but which is seldom formally considered. Non-clinical influences on clinical decision-making profoundly affect medical decisions. These influences include patient-related factors such as socioeconomic status, quality of life and patient's expectations and wishes, physician-related factors such as personal characteristics and interaction with their professional community, and features of clinical practice such as private versus public practice as well as local management policies. This review brings together the different strands of knowledge concerning non-clinical influences on clinical decision-making. This aspect of decision-making may be the biggest obstacle to the reality of practising evidence-based medicine. It needs to be understood in order to develop clinical strategies that will facilitate the practice of evidence-based medicine.
Muir-Cochrane, Eimear; Gerace, Adam; Mosel, Krista; O'Kane, Debra; Barkway, Patricia; Curren, David; Oster, Candice
Risk assessment and management is a major component of contemporary mental health practice. Risk assessment in health care exists within contemporary perspectives of management and risk aversive practices in health care. This has led to much discussion about the best approach to assessing possible risks posed by people with mental health problems. In addition, researchers and commentators have expressed concern that clinical practice is being dominated by managerial models of risk management at the expense of meeting the patient's health and social care needs. The purpose of the present study is to investigate the risk assessment practices of a multidisciplinary mental health service. Findings indicate that mental health professionals draw on both managerial and therapeutic approaches to risk management, integrating these approaches into their clinical practice. Rather than being dominated by managerial concerns regarding risk, the participants demonstrate professional autonomy and concern for the needs of their clients.
Adepoju, Ibukun-Oluwa Omolade; Albersen, Bregje Joanna Antonia; De Brouwere, Vincent; van Roosmalen, Jos; Zweekhorst, M.B.M.
BACKGROUND: In a bid to deliver quality health services in resource-poor settings, mobile health (mHealth) is increasingly being adopted. The role of mHealth in facilitating evidence-based clinical decision-making through data collection, decision algorithms, and evidence-based guidelines, for
De Bock, Ben A.; Willems, Dick L.; Weinstein, Henry C.
How to clarify the implications of complexity thinking for decision making in the intensive care unit (ICU)? Retrospective qualitative empirical research. Practitioners in an ICU were interviewed on how their decisions were made regarding a particular patient in a difficult, clinical situation.
Teran, Felipe; Harper-Kirksey, Katrina; Jagoda, Andy
Seizures and status epilepticus are frequent neurologic emergencies in the emergency department, accounting for 1% of all emergency department visits. The management of this time-sensitive and potentially life-threatening condition is challenging for both prehospital providers and emergency clinicians. The approach to seizing patients begins with differentiating seizure activity from mimics and follows with identifying potential secondary etiologies, such as alcohol-related seizures. The approach to the patient in status epilepticus and the patient with nonconvulsive status epilepticus constitutes a special clinical challenge. This review summarizes the best available evidence and recommendations regarding diagnosis and resuscitation of the seizing patient in the emergency setting.
Razieh, Shahrokhi; Somayeh, Ghafari; Fariba, Haghani
Nurses are one of the most influential factors in overcoming the main challenges faced by health systems throughout the world. Every health system should, hence, empower nurses in clinical judgment and decision-making skills. This study evaluated the effects of implementing Tanner's reflection method on clinical decision-making of nurses working in an intensive care unit (ICU). This study used an experimental, pretest, posttest design. The setting was the intensive care unit of Amin Hospital Isfahan, Iran. The convenience sample included 60 nurses working in the ICU of Amin Hospital (Isfahan, Iran). This clinical trial was performed on 60 nurses working in the ICU of Amin Hospital (Isfahan, Iran). The nurses were selected by census sampling and randomly allocated to either the case or the control group. Data were collected using a questionnaire containing demographic characteristics and the clinical decision-making scale developed by Laurie and Salantera (NDMI-14). The questionnaire was completed before and one week after the intervention. The data were analyzed using SPSS 21.0. The two groups were not significantly different in terms of the level and mean scores of clinical decision-making before the intervention (P = 0.786). Based on the results of independent t-test, the mean score of clinical decision-making one week after the intervention was significantly higher in the case group than in the control group (P = 0.009; t = -2.69). The results of Mann Whitney test showed that one week after the intervention, the nurses' level of clinical decision-making in the case group rose to the next level (P = 0.001). Reflection could improve the clinical decision-making of ICU nurses. It is, thus, recommended to incorporate this method into the nursing curriculum and care practices. Copyright © 2018. Published by Elsevier Ltd.
Légaré, France; Turcotte, Stéphane; Stacey, Dawn; Ratté, Stéphane; Kryworuchko, Jennifer; Graham, Ian D
Shared decision making is the process in which a healthcare choice is made jointly by the health professional and the patient. Little is known about what patients view as effective or ineffective strategies to implement shared decision making in routine clinical practice. This systematic review evaluates the effectiveness of interventions to improve health professionals' adoption of shared decision making in routine clinical practice, as seen by patients. We searched electronic databases (PubMed, the Cochrane Library, EMBASE, CINAHL, and PsycINFO) from their inception to mid-March 2009. We found additional material by reviewing the reference lists of the studies found in the databases; systematic reviews of studies on shared decision making; the proceedings of various editions of the International Shared Decision Making Conference; and the transcripts of the Society for Medical Decision Making's meetings. In our study selection, we included randomized controlled trials, controlled clinical trials, controlled before-and-after studies, and interrupted time series analyses in which patients evaluated interventions to improve health professionals' adoption of shared decision making. The interventions in question consisted of the distribution of printed educational material; educational meetings; audit and feedback; reminders; and patient-mediated initiatives (e.g. patient decision aids). Two reviewers independently screened the studies and extracted data. Statistical analyses considered categorical and continuous process measures. We computed the standardized effect size for each outcome at the 95% confidence interval. The primary outcome of interest was health professionals' adoption of shared decision making as reported by patients in a self-administered questionnaire. Of the 6764 search results, 21 studies reported 35 relevant comparisons. Overall, the quality of the studies ranged from 0% to 83%. Only three of the 21 studies reported a clinically significant effect
Alguera-Lara, Victoria; Dowsey, Michelle M; Ride, Jemimah; Kinder, Skye; Castle, David
We reviewed the literature on shared decision making (regarding treatments in psychiatry), with a view to informing our understanding of the decision making process and the barriers that exist in clinical practice. Narrative review of published English-language articles. After culling, 18 relevant articles were included. Themes identified included models of psychiatric care, benefits for patients, and barriers. There is a paucity of published studies specifically related to antipsychotic medications. Shared decision making is a central part of the recovery paradigm and is of increasing importance in mental health service delivery. The field needs to better understand the basis on which decisions are reached regarding psychiatric treatments. Discrete choice experiments might be useful to inform the development of tools to assist shared decision making in psychiatry.
Thomson, Oliver P; Petty, Nicola J; Moore, Ann P
There is limited understanding of how osteopaths make decisions in relation to clinical practice. The aim of this research was to construct an explanatory theory of the clinical decision-making and therapeutic approaches of experienced osteopaths in the UK. Twelve UK registered osteopaths participated in this constructivist grounded theory qualitative study. Purposive and theoretical sampling was used to select participants. Data was collected using semi-structured interviews which were audio-recorded and transcribed. As the study approached theoretical sufficiency, participants were observed and video-recorded during a patient appointment, which was followed by a video-prompted interview. Constant comparative analysis was used to analyse and code data. Data analysis resulted in the construction of three qualitatively different therapeutic approaches which characterised participants and their clinical practice, termed; Treater, Communicator and Educator. Participants' therapeutic approach influenced their approach to clinical decision-making, the level of patient involvement, their interaction with patients, and therapeutic goals. Participants' overall conception of practice lay on a continuum ranging from technical rationality to professional artistry, and contributed to their therapeutic approach. A range of factors were identified which influenced participants' conception of practice. The findings indicate that there is variation in osteopaths' therapeutic approaches to practice and clinical decision-making, which are influenced by their overall conception of practice. This study provides the first explanatory theory of the clinical decision-making and therapeutic approaches of osteopaths. Copyright © 2013 Elsevier Ltd. All rights reserved.
Hajjaj, F M; Salek, M S; Basra, M K A; Finlay, A Y
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.
Full Text Available Physical restraint is a common nursing intervention in intensive care units and nurses often use it to ensure patients' safety and to prevent unexpected accidents. However, existing literature indicated that the use of physical restraint is a complex one because of inadequate rationales, the negative physical and emotional effects on patients, but the lack of perceived alternatives. This paper is aimed to interpret the clinical decision-making theories related to the use of physical restraint in intensive care units in order to facilitate our understanding on the use of physical restraint and to evaluate the quality of decisions made by nurses. By reviewing the literature, intuition and heuristics are the main decision-making strategies related to the use of physical restraint in intensive care units because the rapid and reflexive nature of intuition and heuristics allow nurses to have a rapid response to urgent and emergent cases. However, it is problematic if nurses simply count their decision-making on experience rather than incorporate research evidence into clinical practice because of inadequate evidence to support the use of physical restraint. Besides that, such a rapid response may lead nurses to make decisions without adequate assessment and thinking and therefore biases and errors may be generated. Therefore, despite the importance of intuition and heuristics in decision-making in acute settings on the use of physical restraint, it is recommended that nurses should incorporate research evidence with their experience to make decisions and adequate assessment before implementing physical restraint is also necessary.
Traynor, Michael; Boland, Maggie; Buus, Niels
Autonomy in decision-making has traditionally been described as a feature of professional work, however the work of healthcare professionals has been seen as steadily encroached upon by State and managerialist forces. Nursing has faced particular problems in establishing itself as a credible....... The study uses accounts of decision-making to gain insight into contemporary professional nursing. The study also aims to explore the usefulness of a theory of professional work set out by Jamous and Peloille (1970). The analysis draws on notions of interpretive repertoires and elements of narrative...... analysis. We identified two interpretive repertoires: 'clinical judgement' which was used to describe the different grounds for making judgements; and 'decision-making' which was used to describe organisational circumstances influencing decision-making. Jamous and Peloille's theory proved useful...
Hajjaj, FM; Salek, MS; Basra, MKA; Finlay, AY
This article reviews an aspect of daily clinical practice which is of critical importance in virtually every clinical consultation, but which is seldom formally considered. Non-clinical influences on clinical decision-making profoundly affect medical decisions. These influences include patient-related factors such as socioeconomic status, quality of life and patient's expectations and wishes, physician-related factors such as personal characteristics and interaction with their professional co...
Gregersen, Trine Ammentorp; Birkelund, Regner; Ammentorp, Jette
Title: Clinical trial or standard treatment? Shared decision making at the department of oncology. Authors: Ph.d. student, Trine A. Gregersen. Trine.email@example.com. Department of Oncology. Health Services Research Unit Lillebaelt Hospital / IRS University of Southern Denmark. Professor, Regner...... are involved in difficult treatment decisions including participation in clinical trials. The literature indicates that the decision is very often based on little knowledge about the treatment and that many patients who have consented to participate in a clinical trial are not always aware...... that they are participating in a trial. This place great demand on the healthcare providers’ ability to involve and advise patients in the decisions. The aim of this study is to investigate the characteristics of the communication when decisions about participation in clinical oncology trial are made and the patients...
Cosh, Suzanne; Zenter, Nadja; Ay, Esra-Sultan; Loos, Sabine; Slade, Mike; De Rosa, Corrado; Luciano, Mario; Berecz, Roland; Glaub, Theodora; Munk-Jørgensen, Povl; Krogsgaard Bording, Malene; Rössler, Wulf; Kawohl, Wolfram; Puschner, Bernd
The study explored relationships between preferences for and experiences of clinical decision making (CDM) with service use among persons with severe mental illness. Data from a prospective observational study in six European countries were examined. Associations of baseline staff-rated (N=213) and patient-rated (N=588) preferred and experienced decision making with service use were examined at baseline by using binomial regressions and at 12-month follow-up by using multilevel models. A preference by patients and staff for active patient involvement in decision making, rather than shared or passive decision making, was associated with longer hospital admissions and higher costs at baseline and with increases in admissions over 12 months (p=.043). Low patient-rated satisfaction with an experienced clinical decision was also related to increased costs over the study period (p=.005). A preference for shared decision making may reduce health care costs by reducing inpatient admissions. Patient satisfaction with decisions was a predictor of costs, and clinicians should maximize patient satisfaction with CDM.
van Baalen, Sophie; Carusi, Annamaria; Sabroe, Ian; Kiely, David G
In recent years there has been growing attention to the epistemology of clinical decision-making, but most studies have taken the individual physicians as the central object of analysis. In this paper we argue that knowing in current medical practice has an inherently social character and that imaging plays a mediating role in these practices. We have analyzed clinical decision-making within a medical expert team involved in diagnosis and treatment of patients with pulmonary hypertension (PH), a rare disease requiring multidisciplinary team involvement in diagnosis and management. Within our field study, we conducted observations, interviews, video tasks, and a panel discussion. Decision-making in the PH clinic involves combining evidence from heterogeneous sources into a cohesive framing of a patient, in which interpretations of the different sources can be made consistent with each other. Because pieces of evidence are generated by people with different expertise and interpretation and adjustments take place in interaction between different experts, we argue that this process is socially distributed. Multidisciplinary team meetings are an important place where information is shared, discussed, interpreted, and adjusted, allowing for a collective way of seeing and a shared language to be developed. We demonstrate this with an example of image processing in the PH service, an instance in which knowledge is distributed over multiple people who play a crucial role in generating an evaluation of right heart function. Finally, we argue that images fulfill a mediating role in distributed knowing in 3 ways: first, as enablers or tools in acquiring information; second, as communication facilitators; and third, as pervasively framing the epistemic domain. With this study of clinical decision-making in diagnosis and treatment of PH, we have shown that clinical decision-making is highly social and mediated by technologies. The epistemology of clinical decision-making needs
Nippita, Tanya A; Porter, Maree; Seeho, Sean K; Morris, Jonathan M; Roberts, Christine L
Unexplained variation in induction of labour (IOL) rates exist between hospitals, even after accounting for casemix and hospital differences. We aimed to explore factors that influence clinical decision-making for IOL that may be contributing to the variation in IOL rates between hospitals. We undertook a qualitative study involving semi-structured, audio-recorded interviews with obstetricians and midwives. Using purposive sampling, participants known to have diverse opinions on IOL were selected from ten Australian maternity hospitals (based on differences in hospital IOL rate, size, location and case-mix complexities). Transcripts were indexed, coded, and analysed using the Framework Approach to identify main themes and subthemes. Forty-five participants were interviewed (21 midwives, 24 obstetric medical staff). Variations in decision-making for IOL were based on the obstetrician's perception of medical risk in the pregnancy (influenced by the obstetrician's personality and knowledge), their care relationship with the woman, how they involved the woman in decision-making, and resource availability. The role of a 'gatekeeper' in the procedural aspects of arranging an IOL also influenced decision-making. There was wide variation in the clinical decision-making practices of obstetricians and less accountability for decision-making in hospitals with a high IOL rate, with the converse occurring in hospitals with low IOL rates. Improved communication, standardised risk assessment and accountability for IOL offer potential for reducing variation in hospital IOL rates.
Marshall, Andrea P; West, Sandra H; Aitken, Leanne M
Variability in clinical practice may result from the use of diverse information sources to guide clinical decisions. In routine clinical practice, nurses privilege information from colleagues over more formal information sources. It is not clear whether similar information-seeking behaviour is exhibited when critical care nurses make decisions about a specific clinical practice, where extensive practice variability exists alongside a developing research base. This study explored the preferred sources of information intensive care nurses used and their perceptions of the accessibility and usefulness of this information for making decisions in clinically uncertain situations specific to enteral feeding practice. An instrumental case study design, incorporating concurrent verbal protocols, Q methodology and focus groups, was used to determine intensive care nurses' perspectives of information use in the resolution of clinical uncertainty. A preference for information from colleagues to support clinical decisions was observed. People as information sources were considered most useful and most accessible in the clinical setting. Text and electronic information sources were seen as less accessible, mainly because of the time required to access the information within the documents. When faced with clinical uncertainty, obtaining information from colleagues allows information to be quickly accessed and applied within the context of a specific clinical presentation. Seeking information from others also provides opportunities for shared decision-making and potential validation of clinical judgment, although differing views may exacerbate clinical uncertainty. The social exchange of clinical information may meet the needs of nurses working in a complex, time-pressured environment but the extent of the evidence base for information passed through verbal communication is unclear. The perceived usefulness and accessibility of information is premised on the ease of use and access
Sims, Deborah; Fowler, Cathrine
The aim of this study is to describe experienced child and family health nurses' clinical decision-making during a postnatal psychosocial assessment. Maternal emotional wellbeing in the postnatal year optimises parenting and promotes infant development. Psychosocial assessment potentially enables early intervention and reduces the risk of a mental disorder occurring during this time of change. Assessment accuracy, and the interventions used are determined by the standard of nursing decision-making. A qualitative methodology was employed to explore decision-making behaviour when conducting a postnatal psychosocial assessment. This study was conducted in an Australian early parenting organisation. Twelve experienced child and family health nurses were interviewed. A detailed description of a postnatal psychosocial assessment process was obtained using a critical incident technique. Template analysis was used to determine the information domains the nurses accessed, and content analysis was used to determine the nurses' thinking strategies, to make clinical decisions from this assessment. The nurses described 24 domains of information and used 17 thinking strategies, in a variety of combinations. The four information domains most commonly used were parenting, assessment tools, women-determined issues and sleep. The seven thinking strategies most commonly used were searching for information, forming relationships between the information, recognising a pattern, drawing a conclusion, setting priorities, providing explanations for the information and judging the value of the information. The variety and complexity of the clinical decision-making involved in postnatal psychosocial assessment confirms that the nurses use information appropriately and within their scope of nursing practice. The standard of clinical decision-making determines the results of the assessment and the optimal access to care. Knowledge of the information domains and the decision-making strategies
Voldbjerg, Siri Lygum; Grønkjaer, Mette; Wiechula, Rick
AIMS AND OBJECTIVES: To explore which knowledge sources newly graduated nurses' use in clinical decision-making and why and how they are used. BACKGROUND: In spite of an increased educational focus on skills and competencies within evidence based practice newly graduated nurses' ability to use...... approaches to strengthen the knowledgebase used in clinical decision-making. DESIGN AND METHODS: Ethnographic study using participant-observation and individual semi-structured interviews of nine Danish newly graduated nurses in medical and surgical hospital settings. RESULTS: Newly graduates use...... in clinical decision-making. If newly graduates are to be supported in an articulate and reflective use of a variety of sources, they have to be allocated to experienced nurses who model a reflective, articulate and balanced use of knowledge sources. This article is protected by copyright. All rights reserved....
Reyna, Valerie F; Nelson, Wendy L; Han, Paul K; Pignone, Michael P
We review decision making along the cancer continuum in the contemporary context of informed and shared decision making in which patients are encouraged to take a more active role in their health care. We discuss challenges to achieving informed and shared decision making, including cognitive limitations and emotional factors, but argue that understanding the mechanisms of decision making offers hope for improving decision support. Theoretical approaches to decision making that explain cognition, emotion, and their interaction are described, including classical psychophysical approaches, dual-process approaches that focus on conflicts between emotion versus cognition (or reason), and modern integrative approaches such as fuzzy-trace theory. In contrast to the earlier emphasis on rote use of numerical detail, modern approaches emphasize understanding the bottom-line gist of options (which encompasses emotion and other influences on meaning) and retrieving relevant social and moral values to apply to those gist representations. Finally, research on interventions to support better decision making in clinical settings is reviewed, drawing out implications for future research on decision making and cancer. PsycINFO Database Record (c) 2015 APA, all rights reserved.
Lim, Amy H; Streeper, Necole M; Best, Sara L; Penniston, Kristina L; Nakada, Stephen Y
Patient decision-making aids (PDMAs) help patients make informed healthcare decisions and improve patient satisfaction. The utility of PDMAs for patients considering treatments for urolithiasis has not yet been published. We report our experience using PDMAs developed at our institution in the outpatient clinical setting in patients considering a variety of treatment options for stones. Patients with radiographically confirmed urolithiasis were given PDMAs regarding treatment options for their stone(s) based on their clinical profile. We assessed patients' satisfaction, involvedness, and feeling of making a more informed decision with utilization of the PDMAs using a Likert Scale Questionnaire. Information was also collected regarding previous stone passage, history and type of surgical intervention for urolithiasis, and level of education. Patients (n = 43; 18 males, 23 females and two unknown) 53 +/- 14years old were included. Patients reported that they understood the advantages and disadvantages outlined in the PDMAs (97%), that the PDMAs helped them make a more informed decision (83%) and felt more involved in the decision making process (88%). Patients reported that the aids were presented in a balanced manner and used up-to-date scientific information (100%, 84% respectively). Finally, a majority of the patients prefer an expert's opinion when making a treatment decision (98%) with 73% of patients preferring to form their own opinion based on available information. Previous stone surgery was associated with patients feeling more involved with the decision making process (p = 0.0465). PDMAs have a promising role in shared decision-making in the setting of treatment options for nephrolithiasis.
Florin, Jan; Ehrenberg, Anna; Ehnfors, Margareta
To investigate predictors of patients' preferences for participation in clinical decision-making in inpatient nursing care. Patient participation in decision-making in nursing care is regarded as a prerequisite for good clinical practice regarding the person's autonomy and integrity. A cross-sectional survey of 428 persons, newly discharged from inpatient care. The survey was conducted using the Control Preference Scale. Multiple logistic regression analysis was used for testing the association of patient characteristics with preferences for participation. Patients, in general, preferred adopting a passive role. However, predictors for adopting an active participatory role were the patient's gender (odds ratio = 1.8), education (odds ratio = 2.2), living condition (odds ratio = 1.8) and occupational status (odds ratio = 2.0). A probability of 53% was estimated, which female senior citizens with at least a high school degree and who lived alone would prefer an active role in clinical decision-making. At the same time, a working cohabiting male with less than a high school degree had a probability of 8% for active participation in clinical decision making in nursing care. Patient preferences for participation differed considerably and are best elicited by assessment of the individual patient. Relevance to clinical practice. The nurses have a professional responsibility to act in such a way that patients can participate and make decisions according to their own values from an informed position. Access to knowledge of patients'basic assumptions and preferences for participation is of great value for nurses in the care process. There is a need for nurses to use structured methods and tools for eliciting individual patient preferences regarding participation in clinical decision-making.
Full Text Available Management of men with prostate cancer is fraught with uncertainty as physicians and patients balance efficacy with potential toxicity and diminished quality of life. Utilization of genomics as a prognostic biomarker has improved the informed decision-making process by enabling more rationale treatment choices. Recently investigations have begun to determine whether genomic information from tumor transcriptome data can be used to impact clinical decision-making beyond prognosis. Here we discuss the potential of genomics to alter management of a patient who presented with high-risk prostate adenocarcinoma. We suggest that this information help selecting patients for advanced imaging, chemotherapies, or clinical trial.
Yanos, Philip T; Garcia, Christine I; Hansell, Stephen; Rosato, Mark G; Minsky, Shula
This study investigated how managed care affects clinical decision-making in a behavioral health care system. Providers serving children and adolescents under both managed and unmanaged care (n = 28) were interviewed about their awareness of differences between the benefit arrangements, how benefits affect clinical decision-making, outcomes and quality of care; and satisfaction with care. Quantitative and qualitative findings indicated that providers saw both advantages and disadvantages to managed care. Although most providers recognized the advantages of managed care in increasing efficiency, many were concerned that administrative pressures associated with managed care compromise service quality.
Hargrave, C; Deegan, T; Gibbs, A; Poulsen, M; Moores, M; Harden, F; Mengersen, K
A decision-making framework for image-guided radiotherapy (IGRT) is being developed using a Bayesian Network (BN) to graphically describe, and probabilistically quantify, the many interacting factors that are involved in this complex clinical process. Outputs of the BN will provide decision-support for radiation therapists to assist them to make correct inferences relating to the likelihood of treatment delivery accuracy for a given image-guided set-up correction. The framework is being developed as a dynamic object-oriented BN, allowing for complex modelling with specific subregions, as well as representation of the sequential decision-making and belief updating associated with IGRT. A prototype graphic structure for the BN was developed by analysing IGRT practices at a local radiotherapy department and incorporating results obtained from a literature review. Clinical stakeholders reviewed the BN to validate its structure. The BN consists of a sub-network for evaluating the accuracy of IGRT practices and technology. The directed acyclic graph (DAG) contains nodes and directional arcs representing the causal relationship between the many interacting factors such as tumour site and its associated critical organs, technology and technique, and inter-user variability. The BN was extended to support on-line and off-line decision-making with respect to treatment plan compliance. Following conceptualisation of the framework, the BN will be quantified. It is anticipated that the finalised decision-making framework will provide a foundation to develop better decision-support strategies and automated correction algorithms for IGRT.
Hargrave, C.; Moores, M.; Deegan, T.; Gibbs, A.; Poulsen, M.; Harden, F.; Mengersen, K.
A decision-making framework for image-guided radiotherapy (IGRT) is being developed using a Bayesian Network (BN) to graphically describe, and probabilistically quantify, the many interacting factors that are involved in this complex clinical process. Outputs of the BN will provide decision-support for radiation therapists to assist them to make correct inferences relating to the likelihood of treatment delivery accuracy for a given image-guided set-up correction. The framework is being developed as a dynamic object-oriented BN, allowing for complex modelling with specific subregions, as well as representation of the sequential decision-making and belief updating associated with IGRT. A prototype graphic structure for the BN was developed by analysing IGRT practices at a local radiotherapy department and incorporating results obtained from a literature review. Clinical stakeholders reviewed the BN to validate its structure. The BN consists of a sub-network for evaluating the accuracy of IGRT practices and technology. The directed acyclic graph (DAG) contains nodes and directional arcs representing the causal relationship between the many interacting factors such as tumour site and its associated critical organs, technology and technique, and inter-user variability. The BN was extended to support on-line and off-line decision-making with respect to treatment plan compliance. Following conceptualisation of the framework, the BN will be quantified. It is anticipated that the finalised decision-making framework will provide a foundation to develop better decision-support strategies and automated correction algorithms for IGRT.
Tranvåg, Eirik Joakim; Norheim, Ole Frithjof; Ottersen, Trygve
Patient age is among the most controversial patient characteristics in clinical decision making. In personalized cancer medicine it is important to understand how individual characteristics do affect practice and how to appropriately incorporate such factors into decision making. Some argue that using age in decision making is unethical, and how patient age should guide cancer care is unsettled. This article provides an overview of the use of age in clinical decision making and discusses how age can be relevant in the context of personalized medicine. We conducted a scoping review, searching Pubmed for English references published between 1985 and May 2017. References concerning cancer, with patients above the age of 18 and that discussed age in relation to diagnostic or treatment decisions were included. References that were non-medical or concerning patients below the age of 18, and references that were case reports, ongoing studies or opinion pieces were excluded. Additional references were collected through snowballing and from selected reports, guidelines and articles. Three hundred and forty-seven relevant references were identified. Patient age can have many and diverse roles in clinical decision making: Contextual roles linked to access (age influences how fast patients are referred to specialized care) and incidence (association between increasing age and increasing incidence rates for cancer); patient-relevant roles linked to physiology (age-related changes in drug metabolism) and comorbidity (association between increasing age and increasing number of comorbidities); and roles related to interventions, such as treatment (older patients receive substandard care) and outcome (survival varies by age). Patient age is integrated into cancer care decision making in a range of ways that makes it difficult to claim age-neutrality. Acknowledging this and being more transparent about the use of age in decision making are likely to promote better clinical decisions
Intuition is widely used in clinical decision making yet its use is underestimated compared to scientific decision-making methods. Information processing is used within scientific decision making and is methodical and analytical, whereas intuition relies more on a practitioner's perception. Intuition is an unconscious process and may be referred to as a 'sixth sense', 'hunch' or 'gut feeling'. It is not underpinned by valid and reliable measures. Expert health professionals use a rapid, automatic process to recognise familiar problems instantly. Intuition could therefore involve pattern recognition, where experts draw on experiences, so could be perceived as a cognitive skill rather than a perception or knowing without knowing how. The NHS places great importance on evidence-based practice but intuition is seemingly becoming an acceptable way of thinking and knowing in clinical decision making. Recognising nursing as an art allows intuition to be used and the environment or situation to be interpreted to help inform decision making. Intuition can be used in conjunction with evidence-based practice and to achieve good outcomes and deserves to be acknowledged within clinical practice.
Djulbegovic, Benjamin; Elqayam, Shira
Given that more than 30% of healthcare costs are wasted on inappropriate care, suboptimal care is increasingly connected to the quality of medical decisions. It has been argued that personal decisions are the leading cause of death, and 80% of healthcare expenditures result from physicians' decisions. Therefore, improving healthcare necessitates improving medical decisions, ie, making decisions (more) rational. Drawing on writings from The Great Rationality Debate from the fields of philosophy, economics, and psychology, we identify core ingredients of rationality commonly encountered across various theoretical models. Rationality is typically classified under umbrella of normative (addressing the question how people "should" or "ought to" make their decisions) and descriptive theories of decision-making (which portray how people actually make their decisions). Normative theories of rational thought of relevance to medicine include epistemic theories that direct practice of evidence-based medicine and expected utility theory, which provides the basis for widely used clinical decision analyses. Descriptive theories of rationality of direct relevance to medical decision-making include bounded rationality, argumentative theory of reasoning, adaptive rationality, dual processing model of rationality, regret-based rationality, pragmatic/substantive rationality, and meta-rationality. For the first time, we provide a review of wide range of theories and models of rationality. We showed that what is "rational" behaviour under one rationality theory may be irrational under the other theory. We also showed that context is of paramount importance to rationality and that no one model of rationality can possibly fit all contexts. We suggest that in context-poor situations, such as policy decision-making, normative theories based on expected utility informed by best research evidence may provide the optimal approach to medical decision-making, whereas in the context
Brown, Richard F.; Shuk, Elyse; Leighl, Natasha; Butow, Phyllis; Ostroff, Jamie; Edgerson, Shawna; Tattersall, Martin
Purpose Slow accrual to cancer clinical trials impedes the progress of effective new cancer treatments. Poor physician–patient communication has been identified as a key contributor to low trial accrual. Question prompt lists (QPLs) have demonstrated a significant promise in facilitating communication in general, surgical, and palliative oncology settings. These simple patient interventions have not been tested in the oncology clinical trial setting. We aimed to develop a targeted QPL for clinical trials (QPL-CT). Method Lung, breast, and prostate cancer patients who either had (trial experienced) or had not (trial naive) participated in a clinical trial were invited to join focus groups to help develop and explore the acceptability of a QPL-CT. Focus groups were audio-recorded and transcribed. A research team, including a qualitative data expert, analyzed these data to explore patients’ decision-making processes and views about the utility of the QPL-CT prompt to aid in trial decision making. Results Decision making was influenced by the outcome of patients’ comparative assessment of perceived risks versus benefits of a trial, and the level of trust patients had in their doctors’ recommendation about the trial. Severity of a patient’s disease influenced trial decision making only for trial-naive patients. Conclusion Although patients were likely to prefer a paternalistic decision-making style, they expressed valuation of the QPL as an aid to decision making. QPL-CT utility extended beyond the actual consultation to include roles both before and after the clinical trial discussion. PMID:20593202
Slosky, Laura E.; Burke, Natasha L.; Siminoff, Laura A.
Background. In stressful situations, decision making processes related to informed consent may be compromised. Given the profound levels of distress that surrogates of children in pediatric intensive care units (PICU) experience, it is important to understand what factors may be influencing the decision making process beyond the informed consent. The purpose of this study was to evaluate the role of clinician influence and other factors on decision making regarding participation in a randomized clinical trial (RCT). Method. Participants were 76 children under sedation in a PICU and their surrogate decision makers. Measures included the Post Decision Clinician Survey, observer checklist, and post-decision interview. Results. Age of the pediatric patient was related to participation decisions in the RCT such that older children were more likely to be enrolled. Mentioning the sponsoring institution was associated with declining to participate in the RCT. Type of health care provider and overt recommendations to participate were not related to enrollment. Conclusion. Decisions to participate in research by surrogates of children in the PICU appear to relate to child demographics and subtleties in communication; however, no modifiable characteristics were related to increased participation, indicating that the informed consent process may not be compromised in this population. PMID:25161672
Sedgwick, M G; Grigg, L; Dersch, S
Rural acute care nursing requires an extensive breadth and depth of knowledge as well as the ability to quickly reason through problems in order to make sound clinical decisions. This reasoning often occurs within an environment that has minimal medical or ancillary support. Registered nurses (RN) new to rural nursing, and employers, have raised concerns about patient safety while new nurses make the transition into rural practice. In addition, feeling unprepared for the rigors of rural hospital nursing practice is a central issue influencing RN recruitment and retention. Understanding how rural RNs reason is a key element for identifying professional development needs and may support recruitment and retention of skilled rural nurses. The purpose of this study was to explore how rural RNs reason through clinical problems as well as to assess the quality of such reasoning. This study used a non-traditional approach for data collection. Fifteen rural acute care nurses with varying years of experience working in southern Alberta, Canada, were observed while they provided care to patients of varying acuity within a simulated rural setting. Following the simulation, semi-structured interviews were conducted using a substantive approach to critical thinking. Findings revealed that the ability to engage in deep clinical reasoning varied considerably among participants despite being given the same information under the same circumstances. Furthermore, the number of years of experience did not seem to be directly linked to the ability to engage in sound clinical reasoning. Novice nurses, however, did rely heavily on others in their decision making in order to ensure they were making the right decision. Hence, their relationships with other staff members influenced their ability to engage in clinical reasoning and decision making. In situations where the patient's condition was deteriorating quickly, regardless of years of experience, all of the participants depended on
Kriston, Levente; Meister, Ramona
Judging applicability (relevance) of meta-analytical findings to particular clinical decision-making situations remains challenging. We aimed to describe an evidence synthesis method that accounts for possible uncertainty regarding applicability of the evidence. We conceptualized uncertainty regarding applicability of the meta-analytical estimates to a decision-making situation as the result of uncertainty regarding applicability of the findings of the trials that were included in the meta-analysis. This trial-level applicability uncertainty can be directly assessed by the decision maker and allows for the definition of trial inclusion probabilities, which can be used to perform a probabilistic meta-analysis with unequal probability resampling of trials (adaptive meta-analysis). A case study with several fictitious decision-making scenarios was performed to demonstrate the method in practice. We present options to elicit trial inclusion probabilities and perform the calculations. The result of an adaptive meta-analysis is a frequency distribution of the estimated parameters from traditional meta-analysis that provides individually tailored information according to the specific needs and uncertainty of the decision maker. The proposed method offers a direct and formalized combination of research evidence with individual clinical expertise and may aid clinicians in specific decision-making situations. Copyright © 2014 Elsevier Inc. All rights reserved.
McGovern, Amanda R; Alexopoulos, George S; Yuen, Genevieve S; Morimoto, Sarah Shizuko; Gunning-Dixon, Faith M
Impairment in reward processes has been found in individuals with depression and in the aging population. The purpose of this study was twofold: (1) to use an affective neuroscience probe to identify abnormalities in reward-related decision making in late-life depression; and (2) to examine the relationship of reward-related decision making abnormalities in depressed, older adults to the clinical expression of apathy in depression. We hypothesized that relative to older, healthy subjects, depressed, older patients would exhibit impaired decision making and that apathetic, depressed patients would show greater impairment in decision making than non-apathetic, depressed patients. We used the Iowa Gambling Task to examine reward-related decision making in 60 non-demented, older patients with non-psychotic major depression and 36 older, psychiatrically healthy participants. Apathy was quantified using the Apathy Evaluation Scale. Of those with major depression, 18 individuals reported clinically significant apathy, whereas 42 participants did not have apathy. Older adults with depression and healthy comparison participants did not differ in their performance on the Iowa Gambling Task. However, apathetic, depressed older adults adopted an advantageous strategy and selected cards from the conservative decks compared with non-apathetic, depressed older adults. Non-apathetic, depressed patients showed a failure to adopt a conservative strategy and persisted in making risky decisions throughout the task. This study indicates that apathy in older, depressed adults is associated with a conservative response style on a behavioral probe of the systems involved in reward-related decision making. This conservative response style may be the result of reduced sensitivity to rewards in apathetic individuals. Copyright © 2014 John Wiley & Sons, Ltd.
Bennett, Casey C; Hauser, Kris
In the modern healthcare system, rapidly expanding costs/complexity, the growing myriad of treatment options, and exploding information streams that often do not effectively reach the front lines hinder the ability to choose optimal treatment decisions over time. The goal in this paper is to develop a general purpose (non-disease-specific) computational/artificial intelligence (AI) framework to address these challenges. This framework serves two potential functions: (1) a simulation environment for exploring various healthcare policies, payment methodologies, etc., and (2) the basis for clinical artificial intelligence - an AI that can "think like a doctor". This approach combines Markov decision processes and dynamic decision networks to learn from clinical data and develop complex plans via simulation of alternative sequential decision paths while capturing the sometimes conflicting, sometimes synergistic interactions of various components in the healthcare system. It can operate in partially observable environments (in the case of missing observations or data) by maintaining belief states about patient health status and functions as an online agent that plans and re-plans as actions are performed and new observations are obtained. This framework was evaluated using real patient data from an electronic health record. The results demonstrate the feasibility of this approach; such an AI framework easily outperforms the current treatment-as-usual (TAU) case-rate/fee-for-service models of healthcare. The cost per unit of outcome change (CPUC) was $189 vs. $497 for AI vs. TAU (where lower is considered optimal) - while at the same time the AI approach could obtain a 30-35% increase in patient outcomes. Tweaking certain AI model parameters could further enhance this advantage, obtaining approximately 50% more improvement (outcome change) for roughly half the costs. Given careful design and problem formulation, an AI simulation framework can approximate optimal
Crowther, Helen J; Kerridge, Ian
Therapies utilized in patients with clinically significant haemoglobin disorders appear to vary between clinicians and units. This study aimed to investigate the processes of evidence implementation and medical decision making in the care of such patients in NSW, Australia. Using semi-structured interviews, 11 haematologists discussed their medical decision-making processes with particular attention paid to the use of published evidence. Transcripts were thematically analysed by a single investigator on a line-by-line basis. Decision making surrounding the care of patients with significant haemoglobin disorders varied and was deeply contextual. Three main determinants of clinical decision making were identified - factors relating to the patient and to their illness, factors specific to the clinician and the institution in which they were practising and factors related to the notion of evidence and to utility and role of evidence-based medicine in clinical practice. Clinicians pay considerable attention to medical decision making and evidence incorporation and attempt to tailor these to particular patient contexts. However, the patient context is often inferred and when discordant with the clinician's own contexture can lead to discomfort with decision recommendations. Clinicians strive to improve comfort through the use of experience and trustworthy evidence. © 2015 John Wiley & Sons, Ltd.
Kozlowski, Desirée; Hutchinson, Marie; Hurley, John; Rowley, Joanne; Sutherland, Joanna
Traditionally, clinical decision making has been perceived as a purely rational and cognitive process. Recently, a number of authors have linked emotional intelligence (EI) to clinical decision making (CDM) and calls have been made for an increased focus on EI skills for clinicians. The objective of this integrative literature review was to identify and synthesise the empirical evidence for a role of emotion in CDM. A systematic search of the bibliographic databases PubMed, PsychINFO, and CINAHL (EBSCO) was conducted to identify empirical studies of clinician populations. Search terms were focused to identify studies reporting clinician emotion OR clinician emotional intelligence OR emotional competence AND clinical decision making OR clinical reasoning. Twenty three papers were retained for synthesis. These represented empirical work from qualitative, quantitative, and mixed-methods approaches and comprised work with a focus on experienced emotion and on skills associated with emotional intelligence. The studies examined nurses (10), physicians (7), occupational therapists (1), physiotherapists (1), mixed clinician samples (3), and unspecified infectious disease experts (1). We identified two main themes in the context of clinical decision making: the subjective experience of emotion; and, the application of emotion and cognition in CDM. Sub-themes under the subjective experience of emotion were: emotional response to contextual pressures; emotional responses to others; and, intentional exclusion of emotion from CDM. Under the application of emotion and cognition in CDM, sub-themes were: compassionate emotional labour - responsiveness to patient emotion within CDM; interdisciplinary tension regarding the significance and meaning of emotion in CDM; and, emotion and moral judgement. Clinicians' experienced emotions can and do affect clinical decision making, although acknowledgement of that is far from universal. Importantly, this occurs in the in the absence of a
dr. Bart Cusveller; Jeanette den Uil-Westerlaken
Bachelor-prepared nurses are expected to be competent in moral deliberation and decision-making (MDD) in clinical practice. It is unclear, however, how this competence develops in nursing students. This study explores the development of nursing students’ competence for participating in organized
Thompson, Carl; Stapley, Sally
Despite the growing popularity of decision making in nursing curricula, the effectiveness of educational interventions to improve nursing judgement and decision making is unknown. We sought to synthesise and summarise the comparative evidence for educational interventions to improve nursing judgements and clinical decisions. A systematic review. Electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, CINAHL and PsycINFO, Social Sciences Citation Index, OpenSIGLE conference proceedings and hand searching nursing journals. Studies published since 1960, reporting any educational intervention that aimed to improve nurses' clinical judgements or decision making were included. Studies were assessed for relevance and quality. Data extracted included study design; educational setting; the nature of participants; whether the study was concerned with the clinical application of skills or the application of theory; the type of decision targeted by the intervention (e.g. diagnostic reasoning) and whether the evaluation of the intervention focused on efficacy or effectiveness. A narrative approach to study synthesis was used due to heterogeneity in interventions, study samples, outcomes and settings and incomplete reporting of effect sizes. From 5262 initial citations 24 studies were included in the review. A variety of educational approaches were reported. Study quality and content reporting was generally poor. Pedagogical theories were widely used but use of decision theory (with the exception of subjective expected utility theory implicit in decision analysis) was rare. The effectiveness and efficacy of interventions was mixed. Educational interventions to improve nurses' judgements and decisions are complex and the evidence from comparative studies does little to reduce the uncertainty about 'what works'. Nurse educators need to pay attention to decision, as well as pedagogical, theory in the design of interventions. Study design and
... page: //medlineplus.gov/ency/patientinstructions/000877.htm Shared decision making To use the sharing features on this page, ... treatment you both support. When to use Shared Decision Making Shared decision making is often used when you ...
Migliore, Alberto; Integlia, Davide; Bizzi, Emanuele; Piaggio, Tomaso
There are plenty of different clinical, organizational and economic parameters to consider in order having a complete assessment of the total impact of a pharmaceutical treatment. In the attempt to follow, a holistic approach aimed to provide an evaluation embracing all clinical parameters in order to choose the best treatments, it is necessary to compare and weight multiple criteria. Therefore, a change is required: we need to move from a decision-making context based on the assessment of one single criteria towards a transparent and systematic framework enabling decision makers to assess all relevant parameters simultaneously in order to choose the best treatment to use. In order to apply the MCDA methodology to clinical decision making the best pharmaceutical treatment (or medical devices) to use to treat a specific pathology, we suggest a specific application of the Multiple Criteria Decision Analysis for the purpose, like a Clinical Multi-criteria Decision Assessment CMDA. In CMDA, results from both meta-analysis and observational studies are used by a clinical consensus after attributing weights to specific domains and related parameters. The decision will result from a related comparison of all consequences (i.e., efficacy, safety, adherence, administration route) existing behind the choice to use a specific pharmacological treatment. The match will yield a score (in absolute value) that link each parameter with a specific intervention, and then a final score for each treatment. The higher is the final score; the most appropriate is the intervention to treat disease considering all criteria (domain an parameters). The results will allow the physician to evaluate the best clinical treatment for his patients considering at the same time all relevant criteria such as clinical effectiveness for all parameters and administration route. The use of CMDA model will yield a clear and complete indication of the best pharmaceutical treatment to use for patients
Hawley, Sarah T; Li, Yun; An, Lawrence C; Resnicow, Kenneth; Janz, Nancy K; Sabel, Michael S; Ward, Kevin C; Fagerlin, Angela; Morrow, Monica; Jagsi, Reshma; Hofer, Timothy P; Katz, Steven J
Purpose This study was conducted to determine the effect of iCanDecide, an interactive and tailored breast cancer treatment decision tool, on the rate of high-quality patient decisions-both informed and values concordant-regarding locoregional breast cancer treatment and on patient appraisal of decision making. Methods We conducted a randomized clinical trial of newly diagnosed patients with early-stage breast cancer making locoregional treatment decisions. From 22 surgical practices, 537 patients were recruited and randomly assigned online to the iCanDecide interactive and tailored Web site (intervention) or the iCanDecide static Web site (control). Participants completed a baseline survey and were mailed a follow-up survey 4 to 5 weeks after enrollment to assess the primary outcome of a high-quality decision, which consisted of two components, high knowledge and values-concordant treatment, and secondary outcomes (decision preparation, deliberation, and subjective decision quality). Results Patients in the intervention arm had higher odds of making a high-quality decision than did those in the control arm (odds ratio, 2.00; 95% CI, 1.37 to 2.92; P = .0004), which was driven primarily by differences in the rates of high knowledge between groups. The majority of patients in both arms made values-concordant treatment decisions (78.6% in the intervention arm and 81.4% in the control arm). More patients in the intervention arm had high decision preparation (estimate, 0.18; 95% CI, 0.02 to 0.34; P = .027), but there were no significant differences in the other decision appraisal outcomes. The effect of the intervention was similar for women who were leaning strongly toward a treatment option at enrollment compared with those who were not. Conclusion The tailored and interactive iCanDecide Web site, which focused on knowledge building and values clarification, positively affected high-quality decisions largely by improving knowledge compared with static online
Maxson, Pamela M; Dozois, Eric J; Holubar, Stefan D; Wrobleski, Diane M; Dube, Joyce A Overman; Klipfel, Janee M; Arnold, Jacqueline J
To determine whether interdisciplinary simulation team training can positively affect registered nurse and/or physician perceptions of collaboration in clinical decision making. Between March 1 and April 21, 2009, a convenience sample of volunteer nurses and physicians was recruited to undergo simulation training consisting of a team response to 3 clinical scenarios. Participants completed the Collaboration and Satisfaction About Care Decisions (CSACD) survey before training and at 2 weeks and 2 months after training. Differences in CSACD summary scores between the time points were assessed with paired t tests. Twenty-eight health care professionals (19 nurses, 9 physicians) underwent simulation training. Nurses were of similar age to physicians (27.3 vs 34.5 years; p = .82), were more likely to be women (95.0% vs 12.5%; p nurses and physicians (p = .04) and that both medical and nursing concerns influence the decision-making process (p = .02). Pretest CSACD analysis revealed that most participants were dissatisfied with the decision-making process. The CSACD summary score showed significant improvement from baseline to 2 weeks (4.2 to 5.1; p nurses and physicians and enhanced the patient care decision-making process.
Michaud, Pierre-André; Blum, Robert Wm; Benaroyo, Lazare; Zermatten, Jean; Baltag, Valentina
The purpose of this article is to provide policy guidance on how to assess the capacity of minor adolescents for autonomous decision-making without a third party authorization, in the field of clinical care. In June 2014, a two-day meeting gathered 20 professionals from all continents, working in the field of adolescent medicine, neurosciences, developmental and clinical psychology, sociology, ethics, and law. Formal presentations and discussions were based on a literature search and the participants' experience. The assessment of adolescent decision-making capacity includes the following: (1) a review of the legal context consistent with the principles of the Convention on the Rights of the Child; (2) an empathetic relationship between the adolescent and the health care professional/team; (3) the respect of the adolescent's developmental stage and capacities; (4) the inclusion, if relevant, of relatives, peers, teachers, or social and mental health providers with the adolescent's consent; (5) the control of coercion and other social forces that influence decision-making; and (6) a deliberative stepwise appraisal of the adolescent's decision-making process. This stepwise approach, already used among adults with psychiatric disorders, includes understanding the different facets of the given situation, reasoning on the involved issues, appreciating the outcomes linked with the decision(s), and expressing a choice. Contextual and psychosocial factors play pivotal roles in the assessment of adolescents' decision-making capacity. The evaluation must be guided by a well-established procedure, and health professionals should be trained accordingly. These proposals are the first to have been developed by a multicultural, multidisciplinary expert panel. Copyright © 2015 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.
Bower, Peter; Macdonald, Wendy; Harkness, Elaine; Gask, Linda; Kendrick, Tony; Valderas, Jose M; Dickens, Chris; Blakeman, Tom; Sibbald, Bonnie
Primary care professionals often manage patients with multiple long-term health conditions, but managing multimorbidity is challenging given time and resource constraints and interactions between conditions. To explore GP and nurse perceptions of multimorbidity and the influence on service organization and clinical decision making. A qualitative interview study with primary care professionals in practices in Greater Manchester, U.K. Interviews were conducted with 15 GPs and 10 practice nurses. Primary care professionals identified tensions between delivering care to meet quality targets and fulfilling the patient's agenda, tensions which are exacerbated in multimorbidity. They were aware of the inconvenience suffered by patients through attendance at multiple clinic appointments when care was structured around individual conditions. They reported difficulties managing patients with multimorbidity in limited consultation time, which led to adoption of an 'additive-sequential' decision-making model which dealt with problems in priority order until consultation resources were exhausted, when further management was deferred. Other challenges included the need for patients to co-ordinate their care, the difficulties of self-management support in multimorbidity and problems of making sense of the relationships between physical and mental health. Doctor and nurse accounts included limited consideration of multimorbidity in terms of the interactions between conditions or synergies between management of different conditions. Primary care professionals identify a number of challenges in care for multimorbidity and adopt a particular model of decision making to deliver care for multiple individual conditions. However, they did not describe specific decision making around managing multimorbidity per se.
Reyna, Valerie F.; Nelson, Wendy L.; Han, Paul K.; Pignone, Michael P.
We review decision-making along the cancer continuum in the contemporary context of informed and shared decision making, in which patients are encouraged to take a more active role in their health care. We discuss challenges to achieving informed and shared decision making, including cognitive limitations and emotional factors, but argue that understanding the mechanisms of decision making offers hope for improving decision support. Theoretical approaches to decision making that explain cogni...
Finch, Elspeth; Geddes, E Lynne; Larin, Hélène
The identification and consideration of relevant ethical issues in clinical decision-making, and the education of health care professionals (HCPs) in these skills are key factors in providing quality health care. This qualitative study explores the way in which physical therapists (PTs) integrate ethical issues into clinical practice decisions and identifies ethical themes used by PTs. A purposive sample of eight PTs was asked to describe a recent ethically-based clinical decision. Transcribed interviews were coded and themes identified related to the following categories: 1) the integration of ethical issues in the clinical decision-making process, 2) patient welfare, 3) professional ethos of the PT, and 4) health care economics and business practices. Participants readily described clinical situations involving ethical issues but rarely identified specific conflicting ethical issues in their description. Ethical dilemmas were more frequently resolved when there were fewer emotional sequelae associated with the dilemma, and the PT had a clear understanding of professional ethos, valued patient autonomy, and explored a variety of alternative actions before implementing one. HCP students need to develop a clear professional ethos and an increased understanding of the economic factors that will present ethical issues in practice.
Pai, Vinay M; Rodgers, Mary; Conroy, Richard; Luo, James; Zhou, Ruixia; Seto, Belinda
In April 2012, the National Institutes of Health organized a two-day workshop entitled 'Natural Language Processing: State of the Art, Future Directions and Applications for Enhancing Clinical Decision-Making' (NLP-CDS). This report is a summary of the discussions during the second day of the workshop. Collectively, the workshop presenters and participants emphasized the need for unstructured clinical notes to be included in the decision making workflow and the need for individualized longitudinal data tracking. The workshop also discussed the need to: (1) combine evidence-based literature and patient records with machine-learning and prediction models; (2) provide trusted and reproducible clinical advice; (3) prioritize evidence and test results; and (4) engage healthcare professionals, caregivers, and patients. The overall consensus of the NLP-CDS workshop was that there are promising opportunities for NLP and CDS to deliver cognitive support for healthcare professionals, caregivers, and patients.
Dobler, Claudia C; Bosnic-Anticevich, Sinthia; Armour, Carol L
The aim of the study was to explore the views of tuberculosis (TB) physicians on treatment of latent TB infection (LTBI), focusing on decision making and communication in clinical practice. 20 Australian TB physicians participated in a semistructured interview in person or over the telephone. Interviews were recorded, transcribed and analysed thematically. The study identified challenges that physicians face when discussing treatment for LTBI with patients. These included difficulties explaining the concept of latency (in particular to patients from culturally and linguistically diverse backgrounds) and providing guidance to patients while still framing treatment decisions as a choice. Tailored estimates of the risk of developing TB and the risk of developing an adverse effect from LTBI treatment were considered the most important information for decision making and discussion with patients. Physicians acknowledged that there is a significant amount of unwarranted treatment variation, which they attributed to the lack of evidence about the risk-benefit balance of LTBI treatment in certain scenarios and guidelines that refer to the need for case-by-case decision making in many instances. In order to successfully implement LTBI treatment at a clinical level, consideration should be given to research on how to best address communication challenges arising in clinical encounters.
Claudia C. Dobler
Full Text Available The aim of the study was to explore the views of tuberculosis (TB physicians on treatment of latent TB infection (LTBI, focusing on decision making and communication in clinical practice. 20 Australian TB physicians participated in a semistructured interview in person or over the telephone. Interviews were recorded, transcribed and analysed thematically. The study identified challenges that physicians face when discussing treatment for LTBI with patients. These included difficulties explaining the concept of latency (in particular to patients from culturally and linguistically diverse backgrounds and providing guidance to patients while still framing treatment decisions as a choice. Tailored estimates of the risk of developing TB and the risk of developing an adverse effect from LTBI treatment were considered the most important information for decision making and discussion with patients. Physicians acknowledged that there is a significant amount of unwarranted treatment variation, which they attributed to the lack of evidence about the risk–benefit balance of LTBI treatment in certain scenarios and guidelines that refer to the need for case-by-case decision making in many instances. In order to successfully implement LTBI treatment at a clinical level, consideration should be given to research on how to best address communication challenges arising in clinical encounters.
Pacheco, José Márcio da Cunha; Gomes, Romeu
This paper analyses the decision making process for senior management in public hospitals that are a part of the National Health Service in Brazil (hereafter SUS) in relation to projects aimed at changing clinical management. The methodological design of this study is qualitative in nature taking a hermeneutics-dialectics perspective in terms of results. Hospital directors noted that clinical management projects changed the state of hospitals through: improving their organizations, mobilizing their staff in order to increase a sense of order and systemizing actions and available resources. Technical rationality was the principal basis used in the decision making process for managers. Due to the reality of many hospitals having fragmented organizations, this fact impeded the use of aspects related to rationality, such as economic and financial factors in the decision making process. The incremental model and general politics also play a role in this area. We concluded that the decision making process embraces a large array of factors including rational aspects such as the use of management techniques and the ability to analyze, interpret and summarize. It also incorporates subjective elements such as how to select values and dealing with people's working experiences. We recognized that management problems are wide in scope, ambiguous, complex and do not come with a lot of structure in practice.
Stiggelbout, A.M.; Vries, M. de; Scherer, L.; Keren, G.; Wu, G.
This chapter presents an overview of the field of medical decision making. It distinguishes the levels of decision making seen in health-care practice and shows how research in judgment and decision making support or improve decision making. Most of the research has been done at the micro level,
Traynor, Michael; Boland, Maggie; Buus, Niels
Autonomy in decision-making has traditionally been described as a feature of professional work, however the work of healthcare professionals has been seen as steadily encroached upon by State and managerialist forces. Nursing has faced particular problems in establishing itself as a credible profession for reasons including history, gender and a traditional subservience to medicine. This paper reports on a focus group study of UK nurses participating in post-qualifying professional development in 2008. Three groups of nurses in different specialist areas comprised a total of 26 participants. The study uses accounts of decision-making to gain insight into contemporary professional nursing. The study also aims to explore the usefulness of a theory of professional work set out by Jamous and Peloille (1970). The analysis draws on notions of interpretive repertoires and elements of narrative analysis. We identified two interpretive repertoires: 'clinical judgement' which was used to describe the different grounds for making judgements; and 'decision-making' which was used to describe organisational circumstances influencing decision-making. Jamous and Peloille's theory proved useful for interpreting instances where the nurses collectively withdrew from the potential dangers of too extreme claims for technicality or indeterminacy in their work. However, their theory did not explain the full range of accounts of decision-making that were given. Taken at face value, the accounts from the participants depict nurses as sometimes practising in indirect ways in order to have influence in the clinical and bureaucratic setting. However, a focus on language use and in particular, interpretive repertoires, has enabled us to suggest that despite an overall picture of severely limited autonomy, nurses in the groups reproduced stories of the successful accomplishment of moral and influential action. Copyright © 2010 Elsevier Ltd. All rights reserved.
Jung, Francis C; Mathew, Sherin; Littmann, Andrew E; MacDonald, Cameron W
Study Design Case series. Background Although growing recognition of cervicogenic dizziness (CGD) is emerging, there is still no gold standard for the diagnosis of CGD. The purpose of this case series is to describe the clinical decision making utilized in the management of 7 patients presenting with CGD. Case Description Patients presenting with neck pain and accompanying subjective symptoms, including dizziness, unsteadiness, light-headedness, and visual disturbance, were selected. Clinical evidence of a temporal relationship between neck pain and dizziness, with or without sensorimotor disturbances, was assessed. Clinical decision making followed a 4-step process, informed by the current available best evidence. Outcome measures included the numeric rating scale for dizziness and neck pain, the Dizziness Handicap Inventory, Patient-Specific Functional Scale, and global rating of change. Outcomes Seven patients (mean age, 57 years; range, 31-86 years; 7 female) completed physical therapy management at an average of 13 sessions (range, 8-30 sessions) over a mean of 7 weeks. Clinically meaningful improvements were observed in the numeric rating scale for dizziness (mean difference, 5.7; 95% confidence interval [CI]: 4.0, 7.5), neck pain (mean difference, 5.4; 95% CI: 3.8, 7.1), and the Dizziness Handicap Inventory (mean difference, 32.6; 95% CI: 12.9, 52.2) at discontinuation. Patients also demonstrated overall satisfaction via the Patient-Specific Functional Scale (mean difference, 9) and global rating of change (mean, +6). Discussion This case series describes the physical therapist decision making, management, and outcomes in patients with CGD. Further investigation is warranted to develop a valid clinical decision-making guideline to inform management of patients with CGD. Level of Evidence Diagnosis, therapy, level 4. J Orthop Sports Phys Ther 2017;47(11):874-884. Epub 9 Oct 2017. doi:10.2519/jospt.2017.7425.
Harris, Ricci; Cormack, Donna; Stanley, James; Curtis, Elana; Jones, Rhys; Lacey, Cameron
Health professional racial/ethnic bias may impact on clinical decision-making and contribute to subsequent ethnic health inequities. However, limited research has been undertaken among medical students. This paper presents findings from the Bias and Decision-Making in Medicine (BDMM) study, which sought to examine ethnic bias (Māori (indigenous peoples) compared with New Zealand European) among medical students and associations with clinical decision-making. All final year New Zealand (NZ) medical students in 2014 and 2015 (n = 888) were invited to participate in a cross-sectional online study. Key components included: two chronic disease vignettes (cardiovascular disease (CVD) and depression) with randomized patient ethnicity (Māori or NZ European) and questions on patient management; implicit bias measures (an ethnicity preference Implicit Association Test (IAT) and an ethnicity and compliant patient IAT); and, explicit ethnic bias questions. Associations between ethnic bias and clinical decision-making responses to vignettes were tested using linear regression. Three hundred and two students participated (34% response rate). Implicit and explicit ethnic bias favoring NZ Europeans was apparent among medical students. In the CVD vignette, no significant differences in clinical decision-making by patient ethnicity were observed. There were also no differential associations by patient ethnicity between any measures of ethnic bias (implicit or explicit) and patient management responses in the CVD vignette. In the depression vignette, some differences in the ranking of recommended treatment options were observed by patient ethnicity and explicit preference for NZ Europeans was associated with increased reporting that NZ European patients would benefit from treatment but not Māori (slope difference 0.34, 95% CI 0.08, 0.60; p = 0.011), although this was the only significant finding in these analyses. NZ medical students demonstrated ethnic bias, although
Tong, Allison; Morton, Rachael L; Webster, Angela C
Patient-centered care is no longer just a buzzword. It is now widely touted as a cornerstone in delivering quality care across all fields of medicine. However, patient-centered strategies and interventions necessitate evidence about patients' decision-making processes, values, priorities, and needs. Qualitative research is particularly well suited to understanding the experience and perspective of patients, donors, clinicians, and policy makers on a wide range of transplantation-related topics including organ donation and allocation, adherence to prescribed therapy, pretransplant and posttransplant care, implementation of clinical guidelines, and doctor-patient communication. In transplantation, evidence derived from qualitative research has been integrated into strategies for shared decision-making, patient educational resources, process evaluations of trials, clinical guidelines, and policies. The aim of this article is to outline key concepts and methods used in qualitative research, guide the appraisal of qualitative studies, and assist clinicians to understand how qualitative research may inform their practice and policy.
Soukup, Tayana; Petrides, Konstantinos V.; Lamb, Benjamin W.; Sarkar, Somita; Arora, Sonal; Shah, Sujay; Darzi, Ara; Green, James S. A.; Sevdalis, Nick
Abstract In the UK, treatment recommendations for patients with cancer are routinely made by multidisciplinary teams in weekly meetings. However, their performance is variable. The aim of this study was to explore the underlying structure of multidisciplinary decision-making process, and examine how it relates to team ability to reach a decision. This is a cross-sectional observational study consisting of 1045 patient reviews across 4 multidisciplinary cancer teams from teaching and community hospitals in London, UK, from 2010 to 2014. Meetings were chaired by surgeons. We used a validated observational instrument (Metric for the Observation of Decision-making in Cancer Multidisciplinary Meetings) consisting of 13 items to assess the decision-making process of each patient discussion. Rated on a 5-point scale, the items measured quality of presented patient information, and contributions to review by individual disciplines. A dichotomous outcome (yes/no) measured team ability to reach a decision. Ratings were submitted to Exploratory Factor Analysis and regression analysis. The exploratory factor analysis produced 4 factors, labeled “Holistic and Clinical inputs” (patient views, psychosocial aspects, patient history, comorbidities, oncologists’, nurses’, and surgeons’ inputs), “Radiology” (radiology results, radiologists’ inputs), “Pathology” (pathology results, pathologists’ inputs), and “Meeting Management” (meeting chairs’ and coordinators’ inputs). A negative cross-loading was observed from surgeons’ input on the fourth factor with a follow-up analysis showing negative correlation (r = −0.19, P < 0.001). In logistic regression, all 4 factors predicted team ability to reach a decision (P < 0.001). Hawthorne effect is the main limitation of the study. The decision-making process in cancer meetings is driven by 4 underlying factors representing the complete patient profile and contributions to case review by all core
Azarpazhooh, Amir; Dao, Thuan; Ungar, Wendy J; Chaudry, Faiza; Figueiredo, Rafael; Krahn, Murray; Friedman, Shimon
To effectively engage patients in clinical decisions regarding the management of teeth with apical periodontitis (AP), there is a need to explore patients' perspectives on the decision-making process. This study surveyed patients for their preferred level of participation in making treatment decisions for a tooth with AP. Data were collected through a mail-out survey of 800 University of Toronto Faculty of Dentistry patients, complemented by a convenience sample of 200 patients from 10 community practices. The Control Preferences Scale was used to evaluate the patients' preferences for active, collaborative, or passive participation in treatment decisions for a tooth with AP. Using bivariate and logistic regression analyses, the Gelberg-Andersen Behavioral Model for Vulnerable Populations was applied to the Control Preferences Scale questions to understand the influential factors (P ≤ .05). Among 434 of 1,000 respondents, 44%, 40%, and 16% preferred an active, collaborative, and passive participation, respectively. Logistic regression showed a significant association (P ≤ .025) between participants' higher education and preference for active participation compared with a collaborative role. Also, immigrant status was significantly associated with preference for passive participation (P = .025). The majority of patients valued an active or collaborative participation in deciding treatment for a tooth with AP. This pattern implied a preference for a patient-centered practice mode that emphasizes patient autonomy in decision making. Copyright © 2014 American Association of Endodontists. Published by Elsevier Inc. All rights reserved.
Fager, Susan; Bardach, Lisa; Russell, Susanne; Higginbotham, Jeff
Children with severe physical impairments require a variety of access options to augmentative and alternative communication (AAC) and computer technology. Access technologies have continued to develop, allowing children with severe motor control impairments greater independence and access to communication. This article will highlight new advances in access technology, including eye and head tracking, scanning, and access to mainstream technology, as well as discuss future advances. Considerations for clinical decision-making and implementation of these technologies will be presented along with case illustrations.
Johnsen, Hege Mari; Fossum, Mariann; Vivekananda-Schmidt, Pirashanthie; Fruhling, Ann; Slettebø, Åshild
The aim of this study was to design and pilot-test a serious game for teaching nursing students clinical reasoning and decision-making skills in caring for patients with chronic obstructive pulmonary disease. A video-based serious game prototype was developed. A purposeful sample of six participants tested and evaluated the prototype. Usability issues were identified regarding functionality and user-computer interface. However, overall the serious game was perceived to be useful, usable and likable to use.
Claudia C. Dobler; Sinthia Bosnic-Anticevich; Carol L. Armour
The aim of the study was to explore the views of tuberculosis (TB) physicians on treatment of latent TB infection (LTBI), focusing on decision making and communication in clinical practice. 20 Australian TB physicians participated in a semistructured interview in person or over the telephone. Interviews were recorded, transcribed and analysed thematically. The study identified challenges that physicians face when discussing treatment for LTBI with patients. These included difficulties explain...
Palmer-Wackerly, Angela L; Dailey, Phokeng M; Krok-Schoen, Jessica L; Rhodes, Nancy D; Krieger, Janice L
When patients are diagnosed with cancer, they begin to negotiate their illness identity in relation to their past and future selves, their relationships, and their group memberships. Thus, how patients view their cancer in relation to their other identities may affect how and why they make particular decisions about treatment options. Using the Communication Theory of Identity (CTI), the current study explores: (1) how and why illness identity is framed across identity layers in relation to one particular cancer treatment: participation in a cancer clinical trial (CT); and (2) how and why patients experience identity conflicts while making their treatment decisions. Semi-structured, in-depth interviews were analyzed for 46 cancer patients who were offered a CT. Results of a grounded theory analysis indicated that patients expressed separate identity frames (e.g., personal, relational, and communal), aligned identity frames (e.g., personal and communal), and identity conflicts (e.g., personal-personal). This study theoretically shows how and why patient illness identity relates to cancer treatment decision-making as well as how and why patients relate (and conflict) with the cancer communal identity frame. Practical implications include how healthcare providers and family members can support patient decision-making through awareness of and accommodating to identity shifts.
Melin-Johansson, Christina; Palmqvist, Rebecca; Rönnberg, Linda
To review what is characteristic of registered nurses' intuition in clinical settings, in relationships and in the nursing process. Intuition is a controversial concept and nurses believe that there are difficulties in how they should explain their nursing actions or decisions based on intuition. Much of the evidence from the body of research indicates that nurses value their intuition in a variety of clinical settings. More information on how nurses integrate intuition as a core element in daily clinical work would contribute to an improved understanding on how they go about this. Intuition deserves a place in evidence-based activities, where intuition is an important component associated with the nursing process. An integrative review strengthened with a mixed-studies review. Literature searches were conducted in the databases CINAHL, PubMed and PsycINFO, and literature published 1985-2016 were included. The findings in the studies were analysed with content analysis, and the synthesis process entailed a reasoning between the authors. After a quality assessment, 16 studies were included. The analysis and synthesis resulted in three categories. The characteristics of intuition in the nurse's daily clinical activities include application, assertiveness and experiences; in the relationships with patients' intuition include unique connections, mental and bodily responses, and personal qualities; and in the nursing process include support and guidance, component and clues in decision-making, and validating decisions. Intuition is more than simply a "gut feeling," and it is a process based on knowledge and care experience and has a place beside research-based evidence. Nurses integrate both analysis and synthesis of intuition alongside objective data when making decisions. They should rely on their intuition and use this knowledge in clinical practice as a support in decision-making, which increases the quality and safety of patient care. We find that intuition plays a
Verdonschot, E.H.A.M.; Liem, S.L.; Palenstein Helderman, W.H. van
By conducting an oral examination, during radiographic examination and in treatment planning procedures dentists make numerous decisions. A dentist will be required to make his decisions explicit. Decision trees and decision analyses may play an important role. In a decision analysis, the
Boehler, Margaret L; Schwind, Cathy J; Markwell, Stephen J; Minter, Rebecca M
Answering pages from nurses about patients in need of immediate attention is one of the most difficult challenges a resident faces during their first days as a physician. A Mock Page program has been developed and adopted into a national surgical resident preparatory curriculum to prepare senior medical students for this important skill. The purpose of this study is to assess standardized mock page cases as a valid construct to assess clinical decision making and interprofessional communication skills. Mock page cases (n = 16) were administered to 213 senior medical students from 12 medical schools participating in a national surgical resident preparatory curriculum in 2013 and 2014. Clinical decision making and interprofessional communication were measured by case-specific assessments evaluating these skills which have undergone rigorous standard-setting to determine pass/fail cut points. Students' performance improved in general for both communication and clinical decision making over the 4-week course. Cases have been identified that seem to be best suited for differentiating high- from low-performing students. Chest pain, pulmonary embolus, and mental status change cases posed the greatest difficulty for student learners. Simulated mock pages demonstrate an innovative technique for training students in both effective interprofessional communication and management of common postoperative conditions they will encounter as new surgical interns.
Légaré, France; Robitaille, Hubert; Gane, Claire; Hébert, Jessica; Labrecque, Michel; Rousseau, François
Knowledge translation (KT) interventions are attempts to change behavior in keeping with scientific evidence. While genetic tests are increasingly available to healthcare consumers in the clinic, evidence about their benefits is unclear and decisions about genetic testing are thus difficult for all parties. We sought to identify KT interventions that involved decisions about genetic testing in the clinical context and to assess their effectiveness for improving decision making in terms of behavior change, increased knowledge and wellbeing. We searched for trials assessing KT interventions in the context of genetic testing up to March 2014 in all systematic reviews (n = 153) published by two Cochrane review groups: Effective Practice and Organisation of Care (EPOC) and Consumers and Communication. We retrieved 2473 unique trials of which we retained only 28 (1%). Two EPOC reviews yielded two trials of KT interventions: audit and feedback (n = 1) and educational outreach (n = 1). Both targeted health professionals and the KT intervention they assessed was found to be effective. Four Consumers and Communication reviews yielded 26 trials: decision aids (n = 15), communication of DNA-based disease risk estimates (n = 7), personalized risk communication (n = 3) and mobile phone messaging (n = 1). Among these, 25 trials targeted only health consumers or patients and the KT interventions were found to be effective in four trials, partly effective in seven, and ineffective in four. Lastly, only one trial targeted both physicians and patients and was found to be effective. More research on the effectiveness of KT interventions regarding genetic testing in the clinical context may contribute to patients making informed value-based decisions and drawing the maximum benefit from clinical applications of genetic and genomic innovations.
Full Text Available Knowledge translation (KT interventions are attempts to change behavior in keeping with scientific evidence. While genetic tests are increasingly available to healthcare consumers in the clinic, evidence about their benefits is unclear and decisions about genetic testing are thus difficult for all parties.We sought to identify KT interventions that involved decisions about genetic testing in the clinical context and to assess their effectiveness for improving decision making in terms of behavior change, increased knowledge and wellbeing.We searched for trials assessing KT interventions in the context of genetic testing up to March 2014 in all systematic reviews (n = 153 published by two Cochrane review groups: Effective Practice and Organisation of Care (EPOC and Consumers and Communication.We retrieved 2473 unique trials of which we retained only 28 (1%. Two EPOC reviews yielded two trials of KT interventions: audit and feedback (n = 1 and educational outreach (n = 1. Both targeted health professionals and the KT intervention they assessed was found to be effective. Four Consumers and Communication reviews yielded 26 trials: decision aids (n = 15, communication of DNA-based disease risk estimates (n = 7, personalized risk communication (n = 3 and mobile phone messaging (n = 1. Among these, 25 trials targeted only health consumers or patients and the KT interventions were found to be effective in four trials, partly effective in seven, and ineffective in four. Lastly, only one trial targeted both physicians and patients and was found to be effective.More research on the effectiveness of KT interventions regarding genetic testing in the clinical context may contribute to patients making informed value-based decisions and drawing the maximum benefit from clinical applications of genetic and genomic innovations.
Clinical decision-making (CDM) is key in learning to be a doctor as the defining activity in their clinical work. CDM is often portrayed in the literature as similar to 'trail blazing'; the doctor as the core agent, clearing away obstacles on the path towards diagnosis and treatment. However, in a fieldwork of young doctors in Denmark, it was difficult connect their practice to this image. This paper presents the exploration of this discrepancy in the heart of medical practice and how an alternative image emerged; that of a 'jam session'. The exploration is represented as a case-based hypothesis-testing: first, a theoretically and empirically informed hypothesis (H0) of how doctors perform CDM is developed. In H0, CDM is a stepwise process of reasoning about clinical data, often influenced by outside contextual factors. Then, H0 is tested against a case from ethnographic fieldwork with doctors going through internship. Although the case is chosen for characteristics that make it 'most likely' to verify the hypothesis, verification proves difficult. The case challenges preconceptions in CDM literature about chronology, context, objectivity, cognition, agency, and practice. The young doctor is found not to make decisions, but rather to participate in CDM; an activity akin to the dynamics found in a jam session. Their participation circles in and through four concurrent interrelated constructions that suggest a new conceptualization of CDM; a starting point for a deeper understanding of actual practice in a changing clinical environment.
Hussain, Ahsen; Oestreicher, James
Diagnostic errors have a significant impact on health care outcomes and patient care. The underlying causes and development of diagnostic error are complex with flaws in health care systems, as well as human error, playing a role. Cognitive biases and a failure of decision-making shortcuts (heuristics) are human factors that can compromise the diagnostic process. We describe these mechanisms, their role with the clinician, and provide clinical scenarios to highlight the various points at which biases may emerge. We discuss strategies to modify the development and influence of these processes and the vulnerability of heuristics to provide insight and improve clinical outcomes. Copyright © 2017 Elsevier Inc. All rights reserved.
Bérubé, J; Papillon, M J; Lavoie, G; Durant, P; Fortin, J P
In the health field, clinical information is the raw material for the clinician delivering health services. Therefore, the clinical information available to the physician is often incomplete or even non¿existent upon consultation. Furthermore, the reconstruction of the medical history, which is the most important source of data for the clinician to establish a diagnosis and initiate a treatment, suffers from many constraints. The smart card, like the one used in Quebec's project, could ease the physician's decision-making by allowing fast access to accurate and pertinent data. The smart card is a major asset in the present health system.
Manuscript. Published version available at http://dx.doi.org/10.1080/13648470.2016.1239695 Clinical decision-making (CDM) is key in learning to be a doctor as the defining activity in their clinical work. CDM is often portrayed in the literature as similar to ‘trail blazing’; the doctor as the core agent, clearing away obstacles on the path towards diagnosis and treatment. However, in a fieldwork of young doctors in Denmark, it was difficult connect their practice to this image....
Hutchinson, Marie; Hurley, John; Kozlowski, Desirée; Whitehair, Leeann
To explore clinical nurses' experiences of using emotional intelligence capabilities during clinical reasoning and decision-making. There has been little research exploring whether, or how, nurses employ emotional intelligence (EI) in clinical reasoning and decision-making. Qualitative phase of a larger mixed-methods study. Semistructured qualitative interviews with a purposive sample of registered nurses (n = 12) following EI training and coaching. Constructivist thematic analysis was employed to analyse the narrative transcripts. Three themes emerged: the sensibility to engage EI capabilities in clinical contexts, motivation to actively engage with emotions in clinical decision-making and incorporating emotional and technical perspectives in decision-making. Continuing to separate cognition and emotion in research, theorising and scholarship on clinical reasoning is counterproductive. Understanding more about nurses' use of EI has the potential to improve the calibre of decisions, and the safety and quality of care delivered. © 2017 John Wiley & Sons Ltd.
Orom, Heather; Biddle, Caitlin; Underwood, Willie; Nelson, Christian J.; Homish, D. Lynn
Objective We explored whether active patient involvement in decision making and greater patient knowledge are associated with better treatment decision making experiences and better quality of life (QOL) among men with clinically localized prostate cancer. Localized prostate cancer treatment decision-making is an advantageous model for studying patient treatment decision-making dynamics as there are multiple treatment options and a lack of empirical evidence to recommend one over the other; consequently, it is recommended that patients be fully involved in making the decision. Methods Men with newly diagnosed clinically localized prostate cancer (N=1529) completed measures of decisional control, prostate cancer knowledge, and their decision-making experience (decisional conflict, and decision-making satisfaction and difficulty) shortly after they made their treatment decision. Prostate cancer-specific QOL was assessed 6-months after treatment. Results More active involvement in decision making and greater knowledge were associated with lower decisional conflict and higher decision-making satisfaction, but greater decision-making difficulty. An interaction between decisional control and knowledge revealed that greater knowledge was only associated with greater difficulty for men actively involved in making the decision (67% of sample). Greater knowledge, but not decisional control predicted better QOL 6-months post-treatment. Conclusion Although men who are actively involved in decision making and more knowledgeable may make more informed decisions, they could benefit from decisional support (e.g., decision-making aids, emotional support from providers, strategies for reducing emotional distress) to make the process easier. Men who were more knowledgeable about prostate cancer and treatment side effects at the time they made their treatment decision may have appraised their QOL as higher because they had realistic expectations about side effects. PMID:26957566
Tanderup, Malene; Reddy, Sunita; Patel, Tulsi; Nielsen, Birgitte Bruun
As a neo-liberal economy, India has become one of the new health tourism destinations, with commercial gestational surrogacy as an expanding market. Yet the Indian Assisted Reproductive Technology (ART) Bill has been pending for five years, and the guidelines issued by the Indian Council of Medical Research are somewhat vague and contradictory, resulting in self-regulated practices of fertility clinics. This paper broadly looks at clinical ethics in reproduction in the practice of surrogacy and decision-making in various procedures. Through empirical research in New Delhi, the capital of India, from December 2011 to November 2012, issues of decision-making on embryo transfer, fetal reduction, and mode of delivery were identified. Interviews were carried out with doctors in eighteen ART clinics, agents from four agencies, and fourteen surrogates. In aiming to fulfil the commissioning parents' demands, doctors were willing to go to the greatest extent possible in their medical practice. Autonomy and decision-making regarding choice of the number of embryos to transfer and the mode of delivery lay neither with commissioning parents nor surrogate mothers but mostly with doctors. In order to ensure higher success rates, surrogates faced the risk of multiple pregnancy and fetal reduction with little information regarding the risks involved. In the globalized market of commercial surrogacy in India, and with clinics compromising on ethics, there is an urgent need for formulation of regulative law for the clinical practice and maintenance of principles of reproductive ethics in order to ensure that the interests of surrogate mothers are safeguarded.
A sound approach to rational decision making requires a decision maker to establish decision objectives, identify alternatives, and evaluate those...often violate the axioms of rationality when making decisions under uncertainty. The systematic description of such observations may lead to the...which leads to “anchoring” on the initial value. The fact that individuals have been shown to deviate from rationality when making decisions
Bennett, Casey C.; Hauser, Kris
In the modern healthcare system, rapidly expanding costs/complexity, the growing myriad of treatment options, and exploding information streams that often do not effectively reach the front lines hinder the ability to choose optimal treatment decisions over time. The goal in this paper is to develop a general purpose (non-disease-specific) computational/artificial intelligence (AI) framework to address these challenges. This serves two potential functions: 1) a simulation environment for expl...
Seger, Carol A; Peterson, Erik J.
We rarely, if ever, repeatedly encounter exactly the same situation. This makes generalization crucial for real world decision making. We argue that categorization, the study of generalizable representations, is a type of decision making, and that categorization learning research would benefit from approaches developed to study the neuroscience of decision making. Similarly, methods developed to examine generalization and learning within the field of categorization may enhance decision making research. We first discuss perceptual information processing and integration, with an emphasis on accumulator models. We then examine learning the value of different decision making choices via experience, emphasizing reinforcement learning modeling approaches. Next we discuss how value is combined with other factors in decision making, emphasizing the effects of uncertainty. Finally, we describe how a final decision is selected via thresholding processes implemented by the basal ganglia and related regions. We also consider how memory related functions in the hippocampus may be integrated with decision making mechanisms and contribute to categorization. PMID:23548891
Foody, JoAnne M; Mendys, Phillip M; Liu, Larry Z; Simpson, Ross J
Contemporary clinical decision making is well supported by a wide variety of information sources, including clinical practice guidelines, position papers, and insights from randomized controlled trials (RCTs). Much of our fundamental understanding of cardiovascular risk factors is based on multiple observations from major epidemiologic studies, such as The Seven Country Studies and the US-based Framingham Heart Study. These studies provided the framework for the development of clinical practice guidelines, including the National Cholesterol Education Program Adult Treatment Panel series. The objective of this article is to highlight the value of observational studies as a complement to clinical trial data for clinical decision making in real-world practice. Although RCTs are still the benchmark for assessing clinical efficacy and safety of a specific therapeutic approach, they may be of limited utility to practitioners who must then adapt the lessons learned from the trial into the patient care environment. The use of well-structured observational studies can improve our understanding of the translation of clinical trials into clinical practice, as demonstrated here with the example of statins. Although such studies have their own limitations, improved techniques for design and analysis have reduced the impact of bias and confounders. The introduction of the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines has provided more uniformity for such studies. When used together with RCTs, observational studies can enhance our understanding of effectiveness and utility in real-world clinical practice. In the examples of statin observational studies, the results suggest that relative effectiveness of different statins and potential impact of switching statins should be carefully considered in treating individual patients by practicing physicians.
Isnawati, Ida; Saukah, Ali
This study investigated teachers' grading decision making, focusing on their beliefs underlying their grading decision making, their grading practices and assessment types, and factors they considered in grading decision making. Two teachers from two junior high schools applying different curriculum policies in grade reporting in Indonesian…
Johnson, S M; Kurtz, M E; Tomlinson, T; Howe, K R
The ability to formulate quick, accurate clinical judgments is stressed in medical training. Speed is usually an asset when a physician sorts through his biomedical knowledge, but it is often a liability when the physician assesses the sociocultural context of a clinical encounter. At the Michigan State University College of Osteopathic Medicine, a study was designed which graphically illustrated to beginning students that unconscious sociocultural stereotypes may influence clinical decision-making. Three entering classes of students were shown a videotape depicting five simulated patients (attractive black woman, attractive white woman, professional man, middle-aged housewife, and elderly man), each presenting with the same physical complaint. Elements of positive and negative stereotypes were incorporated into each of the portrayals, and the students rated these patients on positive and negative characteristics. The results suggested that the students attributed both positive and negative characteristics to patients on the basis of irrelevant characteristics, such as attractiveness, and with little further justification for their attributions. Such stereotypic generalizations held by students may become barriers to the students' objective clinical decision-making.
Edwards, Ian; Richardson, Barbara
Chronic conditions now provide the major disease and disability burden facing humanity. This development has necessitated a reorientation in the practice skills of health care professions away from hospital-based inpatient and outpatient care toward community-based management of patients with chronic conditions. Part of this reorientation toward community-based management of chronic conditions involves practitioners' understanding and adoption of a concept of population health management based on appropriate theoretical models of health care. Drawing on recent studies of expertise in physiotherapy, this article proposes a clinical reasoning and decision-making framework to meet these challenges. The challenge of population and community-based management of chronic conditions also provides an opportunity for physiotherapists to further clarify a professional epistemology of practice that embraces the kinds of knowledge and clinical reasoning processes used in physiotherapy practice. Three case studies related to the management of chronic musculoskeletal pain in different populations are used to exemplify the range of epistemological perspectives that underpin community-based practice. They illustrate the link between conceptualizations of practice problems and knowledge sources that are used as a basis for clinical reasoning and decision making as practitioners are increasingly required to move between the clinic and the community.
Lam, Daniel; Egan, Ingrid; Baird, Marilyn
This pilot study attempts to quantify the benefits of a documented radiographic clinical history through the use of the clinical history template form designed by Egan and Baird. Six radiographers completed the clinical history template for 40 patients and four radiologists included the recorded information as part of their reporting process. A focus discussion group was held between the radiographers to ascertain the level of satisfaction and benefits encountered with the use of the template form. A questionnaire was designed for the radiologists to complete regarding the usefulness of the template form with respect to the radiological reporting process. Results/Discussion: 15 cases for which the form was used demonstrated a direct benefit in respect to improved radiographic clinical decision-making. Radiographers agreed the template form aided the establishment of a stronger radiographer-patient relationship during the radiographic examination. Two radiologists agreed the form aided in establishing a radiological diagnosis and suggested the form be implemented as part of the standard departmental protocol. Despite the small sample size, there is evidence the form aided radiographic decision-making and assisted in the establishment of an accurate radiological diagnosis. The overall consensus amongst radiographers was that it enhanced radiographer-patient communication and improved the level of patient care. Copyright (2004) Australian Institute of Radiography
Ranieri, Veronica F; Barratt, Helen; Rees, Geraint; Fulop, Naomi J
To describe the influences on clinical academic physicians' postdoctoral career decision-making. Thirty-five doctoral trainee physicians from University College London took part in semi-structured interviews in 2015 and 2016. Participants were asked open-ended questions about their career to-date, their experiences undertaking a PhD, and their career plans post-PhD. The interviews were audio-recorded and transcribed. Thematic analysis was used to generate, review, and define themes from the transcripts. Emerging differences and similarities in participants' reasons for pursuing a PhD were then grouped to produce typologies to explore how their experiences influenced their career decision-making. Participants described four key reasons for undertaking a PhD, which formed the basis of the four typologies identified. These reasons included: to pursue a clinical academic career; to complete an extensive period of research to understand whether a clinical academic career was the desired path forward; to improve clinical career prospects; and to take a break from clinical training. These findings highlight the need to target efforts at retaining clinical academic physicians according to their reasons for pursuing a PhD and their subsequent experiences with the process. Those responsible for overseeing clinical training must be well-informed of the long-term benefits of training academically-qualified physicians. In light of current political uncertainty, universities, hospitals, and external agencies alike must increase their efforts to inspire and assuage early-career clinical academic physicians' fears regarding their academic future.This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Harbeck, Nadia; Sotlar, Karl; Wuerstlein, Rachel; Doisneau-Sixou, Sophie
In early breast cancer (eBC), established clinicopathological factors are not sufficient for clinical decision making particularly regarding adjuvant chemotherapy since substantial over- or undertreatment may occur. Thus, novel protein- and molecular markers have been put forward as decision aids. Since these potential prognosis and/or predictive tests differ substantially regarding their methodology, analytical and clinical validation, this review attempts to summarize the essential facts for clinicians. This review focuses on those markers which are the most advanced so far in their development towards routine clinical application, i.e. two protein markers (i.e. uPA/PAI-1 and IHC4) and six molecular multigene tests (i.e. Mammaprint®, Oncotype DX®, PAM50, Endopredict®, the 97-gene genomic grade, and 76 gene Rotterdam signatures). Next to methodological aspects, we summarized the clinical evidences, in particular the main prospective clinical trials which have already been fully recruited (i.e. MINDACT, TAILORx, WSG PLAN B) or are still ongoing (i.e. RxPONDER/SWOG S1007, WSG-ADAPT). Last but not least, this review points out the key elements for clinicians to select one test among the wide panel of proposed assays, for a specific population of patients in term of level of evidence, analytical and clinical validity as well as cost effectiveness. Copyright © 2013 Elsevier Ltd. All rights reserved.
Leonardo Yuji Tamura
Full Text Available Quantum Electronics was a Brazilian startup in the 1990's that was acquired by an American equity fund in 2012. They are currently the largest manufacturer of vehicle tracking and infotainment systems. The company was founded by three college friends, who are currently executives at the company: Camilo Santos, Pedro Barbosa and Luana Correa. Edward Hutter was sent by the equity fund to take over the company’s finances, but is having trouble making organizational decisions with his colleagues. As a consultant, I was called to help them improve their decision making process and project prioritization. I adapted and deployed our firm's methodology, but, in the end, its adequacy is shown to be very much in question. The author of this case study intends to explore how actual organizational decisions rely on different decision models and their assumptions, .as well as demonstrate that a decision model is neither absolutely good nor bad as its quality is context dependent.
Full Text Available Abstract Background There is considerable interest today in shared decision-making (SDM, defined as a decision-making process jointly shared by patients and their health care provider. However, the data show that SDM has not been broadly adopted yet. Consequently, the main goal of this proposal is to bring together the resources and the expertise needed to develop an interdisciplinary and international research team on the implementation of SDM in clinical practice using a theory-based dyadic perspective. Methods Participants include researchers from Canada, US, UK, and Netherlands, representing medicine, nursing, psychology, community health and epidemiology. In order to develop a collaborative research network that takes advantage of the expertise of the team members, the following research activities are planned: 1 establish networking and on-going communication through internet-based forum, conference calls, and a bi-weekly e-bulletin; 2 hold a two-day workshop with two key experts (one in theoretical underpinnings of behavioral change, and a second in dyadic data analysis, and invite all investigators to present their views on the challenges related to the implementation of SDM in clinical practices; 3 conduct a secondary analyses of existing dyadic datasets to ensure that discussion among team members is grounded in empirical data; 4 build capacity with involvement of graduate students in the workshop and online forum; and 5 elaborate a position paper and an international multi-site study protocol. Discussion This study protocol aims to inform researchers, educators, and clinicians interested in improving their understanding of effective strategies to implement shared decision-making in clinical practice using a theory-based dyadic perspective.
Ucuzal, Meral; Doğan, Runida
Pain is the most common reason that patients come to the emergency department. Emergency nurses have an indispensable role in the management of this pain. The aim of this study was to examine emergency nurses' knowledge, attitude and clinical decision-making skills about pain. This descriptive study was conducted in a state and a university hospital between September and October 2012 in Malatya, Turkey. Of 98 nurses working in the emergency departments of these two hospitals, 57 returned the questionnaires. The response rate was 58%. Data were collected using the Demographic Information Questionnaire, Knowledge and Attitude Questionnaire about Pain and Clinical Decision Making Survey. Frequency, percentage, mean and standard deviation were used to evaluate data. 75.4% of participant nurses knew that patients' own statement about their pain was the most reliable indicator during pain assessment. Almost half of the nurses believed that patients should be encouraged to endure the pain as much as possible before resorting to a pain relief method. The results also indicate that most of nurses think that a sleeping patient does not have any pain and pain relief should be postponed as it can influence the diagnosis negatively. It is determined that the pain scale was not used frequently. Only 35.1% of nurses reported keeping records of pain. Despite all the recommendations of substantial past research the results of this study indicate that emergency nurses continue to demonstrate inadequate knowledge, clinical decision-making skills and negative attitudes about pain. Copyright © 2014 Elsevier Ltd. All rights reserved.
David F. Kisor
Full Text Available Objective: To evaluate a pilot of a laboratory model for relating pharmacogenetics to clinical decision making. Case Study: This pilot was undertaken and evaluated to help determine if a pharmacogenetics laboratory should be included in the core Doctor of Pharmacy curriculum. The placement of the laboratory exercise in the curriculum was determined by identifying the point in the curriculum where the students had been introduced to the chemistry of deoxyribonucleic acid (DNA as well as instructed on the chemistry of genetic variation. The laboratory included cytochrome P450 2C19 genotyping relative to the *2 variant. Twenty-four students served as the pilot group. Students provided buccal swabs as the source of DNA. Students stabilized the samples and were then provided instructions related to sample preparation, polymerase chain reaction, and gel electrophoresis. The results were reported as images of gels. Students used a reference gel image to compare their results to. Students then applied a dosing algorithm to make a "clinical decision" relative to clopidogrel use. Students were offered a post laboratory survey regarding attitudes toward the laboratory. Twenty-four students completed the laboratory with genotyping results being provided for 22 students (91.7%. Sixteen students were wild-type (*1/*1, while six students were heterozygous (*1/*2. Twenty-three students (96% completed the post laboratory survey. All 23 agreed (6, 26.1% or strongly agreed (17, 73.9% that the laboratory "had relevance and value in the pharmacy curriculum" Conclusion: The post pilot study survey exploring a laboratory model for pharmacogenetics related to clinical decision making indicated that such a laboratory would be viewed positively by students. This model may be adopted by colleges to expand pharmacogenetics education. Type: Case Study
Braverman, Jennifer A; Blumenthal-Barby, J S
Despite the current push toward the practice of evidence-based medicine and comparative effectiveness research, clinicians' decisions may be influenced not only by evidence, but also by cognitive biases. A cognitive bias describes a tendency to make systematic errors in certain circumstances based on cognitive factors rather than evidence. Though health care providers have been shown in several studies to be susceptible to a variety of types of cognitive biases, research on the role of the sunk-cost bias in clinical decision-making is extremely limited. The sunk-cost bias is the tendency to pursue a course of action, even after it has proved to be suboptimal, because resources have been invested in that course of action. This study explores whether health care providers' medical treatment recommendations are affected by prior investments in a course of treatment. Specifically, we surveyed 389 health care providers in a large urban medical center in the United States during August 2009. We asked participants to make a treatment recommendation based on one of four hypothetical clinical scenarios that varied in the source and type of prior investment described. By comparing recommendations across scenarios, we found that providers did not demonstrate a sunk-cost effect; rather, they demonstrated a significant tendency to over-compensate for the effect. In addition, we found that more than one in ten health care providers recommended continuation of an ineffective treatment. Copyright © 2012 Elsevier Ltd. All rights reserved.
Djulbegovic, B.; Elqayam, Shira
open access article Given that more than 30% of healthcare costs are wasted on inappropriate care, suboptimal care is increasingly connected to the quality of medical decisions. It has been argued that personal decisions are the leading cause of death, and 80% of healthcare expenditures result from physicians' decisions. Therefore, improving healthcare necessitates improving medical decisions, ie, making decisions (more) rational. Drawing on writings fromThe Great Rationality Debate from t...
Enrique Benjamín Franklin Fincowsky
Full Text Available People and organizations make better or get wrong as consequence of making decisions. Sometimes making decisions is just a trial and error process. Some others, decisions are good and the results profitable with a few of mistakes, most of the time because it’s considered the experience and the control of a specific field or the good intention of who makes them. Actually, all kinds of decisions bring learning. What is important is the intention, the attitude and the values considered in this process. People from different scenes face many facts and circumstances—almost always out of control—that affect the making decisions process. There is not a unique way to make decisions for all companies in many settings. The person who makes a decision should identify the problem, to solve it later using alternatives and solutions. Even though, follow all the steps it’s not easy as it seems. Looking back the conditions related to the decisions, we can mention the followings: uncertainty, risk and certainty. When people identify circumstances and facts, as well as its effects in a possible situation, they will make decisions with certainty. As long as the information decreases and it becomes ambiguous the risk becomes an important factor in the making decisions process because they are connected to probable objectives (clear or subjective (opinion judgment or intuition. To finish, uncertainty, involves people that make a decision with no or little information about circumstances or criteria with basis
Full Text Available The purpose of this study was to identify clinician characteristics associated with higher prescription rates of long-acting injectable (LAI antipsychotics, as well as the sources that influence medical decision-making regarding the treatment of schizophrenia. We surveyed 202 psychiatrists during six regional French conferences (Bordeaux, Lyon, Marseille, Nice, Paris, and Strasbourg. Data on the characteristics of practice, prescription rates of antipsychotic, and information sources about their clinical decisions were collected. Most psychiatrists used second-generation antipsychotics (SGAs, and preferentially an oral formulation, in the treatment of schizophrenia. LAI SGAs were prescribed to 30.4% of schizophrenic patients. The duration and type of practice did not influence the class or formulation of antipsychotics used. The clinicians following the higher percentage of schizophrenic patients were associated with a higher use of LAI antipsychotics and a lower use of oral SGAs. Personal experience, government regulatory approval, and guidelines for the treatment of schizophrenia were the three main contributing factors guiding clinicians’ decision-making regarding the treatment of schizophrenia. The more clinicians follow schizophrenic patients, the more they use LAI antipsychotics. The development of specialized programs with top specialists should lead to better use of LAI antipsychotics in the treatment of schizophrenia.
Clarke, Jonathan; Puertas, Renata; Kotecha, Aachal; Foster, Paul J; Barton, Keith
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/.
Bozzaro, Claudia; Schildmann, Jan
Palliative sedation is an increasingly used and, simultaneously, challenging practice at the end of life. Many controversies associated with this therapy are rooted in implicit differences regarding the understanding of "suffering" as prerequisite for palliative sedation. The aim of this paper is to inform the current debates by a conceptual analysis of two different philosophical accounts of suffering, (1) the subjective and holistic concept and (2) the objective and gradual concept and by a clinical-ethical analysis of the implications of each account for decisions about palliative sedation. We will show that while the subjective and holistic account of suffering fits well with the holistic approach of palliative care, there are considerable challenges to justify limits to requests for palliative sedation. By contrast, the objective and gradual account fits well with the need for an objective basis for clinical decisions in the context of palliative sedation, but runs the risk of falling short when considering the individual and subjective experience of suffering at the end of life. We will conclude with a plea for the necessity of further combined conceptual and empirical research to develop a sound and feasible understanding of suffering which can contribute to consistent decision-making about palliative sedation. Copyright © 2018. Published by Elsevier Inc.
Dolan, James G
Current models of healthcare quality recommend that patient management decisions be evidence-based and patient-centered. Evidence-based decisions require a thorough understanding of current information regarding the natural history of disease and the anticipated outcomes of different management options. Patient-centered decisions incorporate patient preferences, values, and unique personal circumstances into the decision making process and actively involve both patients along with health care providers as much as possible. Fundamentally, therefore, evidence-based, patient-centered decisions are multi-dimensional and typically involve multiple decision makers.Advances in the decision sciences have led to the development of a number of multiple criteria decision making methods. These multi-criteria methods are designed to help people make better choices when faced with complex decisions involving several dimensions. They are especially helpful when there is a need to combine "hard data" with subjective preferences, to make trade-offs between desired outcomes, and to involve multiple decision makers. Evidence-based, patient-centered clinical decision making has all of these characteristics. This close match suggests that clinical decision support systems based on multi-criteria decision making techniques have the potential to enable patients and providers to carry out the tasks required to implement evidence-based, patient-centered care effectively and efficiently in clinical settings.The goal of this paper is to give readers a general introduction to the range of multi-criteria methods available and show how they could be used to support clinical decision-making. Methods discussed include the balance sheet, the even swap method, ordinal ranking methods, direct weighting methods, multi-attribute decision analysis, and the analytic hierarchy process (AHP).
Müller-Staub, Maria; Stuker-Studer, Ursula
Case studies, based on actual patients' situations, provide a method of clinical decision making to foster critical thinking in nurses. This paper describes the method and process of group case studies applied in continuous education settings. This method bases on Balints' case supervision and was further developed and combined with the nursing diagnostic process. A case study contains different phases: Pre-phase, selection phase, case delineation and case work. The case provider narratively tells the situation of a patient. This allows the group to analyze and cluster signs and symptoms, to state nursing diagnoses and to derive nursing interventions. Results of the case study are validated by applying the theoretical background and critical appraisal of the case provider. Learning effects of the case studies were evaluated by means of qualitative questionnaires and analyzed according to Mayring. Findings revealed the following categories: a) Patients' problems are perceived in a patient centred way, accurate nursing diagnoses are stated and effective nursing interventions implemented. b) Professional nursing tasks are more purposefully perceived and named more precise. c) Professional nursing relationship, communication and respectful behaviour with patients were perceived in differentiated ways. The theoretical framework is described in the paper "Clinical decision making and critical thinking in the nursing diagnostic process". (Müller-Staub, 2006).
Chahine, Saad; Cristancho, Sayra; Padgett, Jessica; Lingard, Lorelei
In the competency-based medical education (CBME) approach, clinical competency committees are responsible for making decisions about trainees' competence. However, we currently lack a theoretical model for group decision-making to inform this emerging assessment phenomenon. This paper proposes an organizing framework to study and guide the decision-making processes of clinical competency committees.This is an explanatory, non-exhaustive review, tailored to identify relevant theoretical and evidence-based papers related to small group decision-making. The search was conducted using Google Scholar, Web of Science, MEDLINE, ERIC, and PsycINFO for relevant literature. Using a thematic analysis, two researchers (SC & JP) met four times between April-June 2016 to consolidate the literature included in this review.Three theoretical orientations towards group decision-making emerged from the review: schema, constructivist, and social influence. Schema orientations focus on how groups use algorithms for decision-making. Constructivist orientations focus on how groups construct their shared understanding. Social influence orientations focus on how individual members influence the group's perspective on a decision. Moderators of decision-making relevant to all orientations include: guidelines, stressors, authority, and leadership.Clinical competency committees are the mechanisms by which groups of clinicians will be in charge of interpreting multiple assessment data points and coming to a shared decision about trainee competence. The way in which these committees make decisions can have huge implications for trainee progression and, ultimately, patient care. Therefore, there is a pressing need to build the science of how such group decision-making works in practice. This synthesis suggests a preliminary organizing framework that can be used in the implementation and study of clinical competency committees.
Angela Smith, PharmD Candidate
Full Text Available Objective: To evaluate a pilot of a laboratory model for relating pharmacogenetics to clinical decision making. Case Study: This pilot was undertaken and evaluated to help determine if a pharmacogenetics laboratory should be included in the core Doctor of Pharmacy curriculum. The placement of the laboratory exercise in the curriculum was determined by identifying the point in the curriculum where the students had been introduced to the chemistry of deoxyribonucleic acid (DNA as well as instructed on the chemistry of genetic variation. The laboratory included cytochrome P450 2C19 genotyping relative to the *2 variant. Twenty-four students served as the pilot group. Students provided buccal swabs as the source of DNA. Students stabilized the samples and were then provided instructions related to sample preparation, polymerase chain reaction, and gel electrophoresis. The results were reported as images of gels. Students used a reference gel image to compare their results to. Students then applied a dosing algorithm to make a “clinical decision” relative to clopidogrel use. Students were offered a post laboratory survey regarding attitudes toward the laboratory. Twenty-four students completed the laboratory with genotyping results being provided for 22 students (91.7%. Sixteen students were wild-type (*1/*1, while six students were heterozygous (*1/*2. Twenty-three students (96% completed the post laboratory survey. All 23 agreed (6, 26.1% or strongly agreed (17, 73.9% that the laboratory “had relevance and value in the pharmacy curriculum”. Conclusion: The post pilot study survey exploring a laboratory model for pharmacogenetics related to clinical decision making indicated that such a laboratory would be viewed positively by students. This model may be adopted by colleges to expand pharmacogenetics education.
Legare, F.; Elwyn, G.; Fishbein, M.; Fremont, P.; Frosch, D.; Gagnon, M.P.; Kenny, D.A.; Labrecque, M.; Stacey, D.; St-Jacques, S.; Weijden, G.D.E.M. van der
ABSTRACT: BACKGROUND: There is considerable interest today in shared decision-making (SDM), defined as a decision-making process jointly shared by patients and their health care provider. However, the data show that SDM has not been broadly adopted yet. Consequently, the main goal of this proposal
Loughlin, Michael; Bluhm, Robyn; Buetow, Stephen; Borgerson, Kirstin; Fuller, Jonathan
When the editorial to the first philosophy thematic edition of this journal was published in 2010, critical questioning of underlying assumptions, regarding such crucial issues as clinical decision making, practical reasoning, and the nature of evidence in health care, was still derided by some prominent contributors to the literature on medical practice. Things have changed dramatically. Far from being derided or dismissed as a distraction from practical concerns, the discussion of such fundamental questions, and their implications for matters of practical import, is currently the preoccupation of some of the most influential and insightful contributors to the on-going evidence-based medicine debate. Discussions focus on practical wisdom, evidence, and value and the relationship between rationality and context. In the debate about clinical practice, we are going to have to be more explicit and rigorous in future in developing and defending our views about what is valuable in human life. © 2017 John Wiley & Sons, Ltd.
Yoo, Moon-Sook; Park, Jin-Hee; Lee, Si-Ra
The purpose of this study was to examine the effects of case-base learning (CBL) using video on clinical decision-making and learning motivation. This research was conducted between June 2009 and April 2010 as a nonequivalent control group non-synchronized design. The study population was 44 third year nursing students who enrolled in a college of nursing, A University in Korea. The nursing students were divided into the CBL and the control group. The intervention was the CBL with three cases using video. The controls attended a traditional live lecture on the same topics. With questionnaires objective clinical decision-making, subjective clinical decision-making, and learning motivation were measured before the intervention, and 10 weeks after the intervention. Significant group differences were observed in clinical decision-making and learning motivation. The post-test scores of clinical decision-making in the CBL group were statistically higher than the control group. Learning motivation was also significantly higher in the CBL group than in the control group. These results indicate that CBL using video is effective in enhancing clinical decision-making and motivating students to learn by encouraging self-directed learning and creating more interest and curiosity in learning.
Noland, Shelley S; Krauss, Emily M; Felder, John M; Mackinnon, Susan E
Isolated long thoracic nerve palsy results in scapular winging and destabilization. In this study, we review the surgical management of isolated long thoracic nerve palsy and suggest a surgical technique and treatment algorithm to simplify management. In total, 19 patients who required surgery for an isolated long thoracic nerve palsy were reviewed retrospectively. Preoperative demographics, electromyography (EMG), and physical examinations were reviewed. Intraoperative nerve stimulation, surgical decision making, and postoperative outcomes were reviewed. In total, 19 patients with an average age of 32 were included in the study. All patients had an isolated long thoracic nerve palsy caused by either an injury (58%), Parsonage-Turner syndrome (32%), or shoulder surgery (10%); 18 patients (95%) underwent preoperative EMG; 10 with evidence of denervation (56%); and 13 patients had motor unit potentials in the serratus anterior (72%). The preoperative EMG did not correlate with intraoperative nerve stimulation in 13 patients (72%) and did correlate in 5 patients (28%); 3 patients had a nerve transfer (3 thoracodorsal to long thoracic at lateral chest, 1 pec to long thoracic at supraclavicular incision). In the 3 patients who had a nerve transfer, there was return of full forward flexion of the shoulder at an average of 2.5 months. A treatment algorithm based on intraoperative nerve stimulation will help guide surgeons in their clinical decision making in patients with isolated long thoracic nerve palsy. Intraoperative nerve stimulation is the gold standard in the management of isolated long thoracic nerve palsy.
Dall, Sasha R. X.; Gosling, Samuel; Gordon D.A., Brown,; Dingemanse, Niels; Ido, Erev,; Martin, Kocher,; Laura, Schulz,; Todd, Peter M; Weissing, Franz; Wolf, Max; Hammerstein, Peter; Stevens, Jeffrey R.
Variation in how organisms allocate their behavior over their lifetimes is key to determining Darwinian fitness., and thus the evolution of human and nonhuman decision making. This chapter explores how decision making varies across biologically and societally significant scales and what role such
Advises directors of ways to include day care workers in the decision-making process. Enumerates benefits of using staff to help focus and direct changes in the day care center and discusses possible pitfalls in implementation of a collective decision-making approach to management. (NH)
Wu, Min; Yang, Jinqiu; Liu, Lingying; Ye, Benlan
This study aims to investigate the influencing factors on nurses' clinical decision-making (CDM) skills. A cross-sectional nonexperimental research design was conducted in the medical, surgical, and emergency departments of two university hospitals, between May and June 2014. We used a quantile regression method to identify the influencing factors across different quantiles of the CDM skills distribution and compared the results with the corresponding ordinary least squares (OLS) estimates. Our findings revealed that nurses were best at the skills of managing oneself. Educational level, experience, and the total structural empowerment had significant positive impacts on nurses' CDM skills, while the nurse-patient relationship, patient care and interaction, formal empowerment, and information empowerment were negatively correlated with nurses' CDM skills. These variables explained no more than 30% of the variance in nurses' CDM skills and mainly explained the lower quantiles of nurses' CDM skills distribution. © The Author(s) 2016.
Approved for public release; distribution is unlimited This thesis develops a heuristic approach to organizational decision-making by synthesizing the classical, neo-classical and contingency approaches to organization theory. The conceptual framework developed also integrates the rational and cybernetic approaches with cognitive processes underlying the decision-making process. The components of the approach address the role of environment in organizational decision-maki...
Moberg, Paul J; Rick, Jacqueline H
With our ageing population, the number of older adults with cognitive impairment has also increased. There is both an acute and growing need for evidence-based assessments to identify their decision making capacity and competence. In the present article we (1) present definitions of decision-making capacity and competence, (2) review cognitive functions that are central to decision-making capacity as well as the methods and procedures commonly used to assess these domains, and (3) address the communication of assessment findings to patients and their loved ones. The importance of assessing decision-making capacity in the context of specific functions and of respecting the values and interests of older adults are emphasized.
Orasanu, Judith; Statler, Irving C. (Technical Monitor)
The importance of decision-making to safety in complex, dynamic environments like mission control centers and offshore installations has been well established. NASA-ARC has a program of research dedicated to fostering safe and effective decision-making in the manned spaceflight environment. Because access to spaceflight is limited, environments with similar characteristics, including aviation and nuclear power plants, serve as analogs from which space-relevant data can be gathered and theories developed. Analyses of aviation accidents cite crew judgement and decision making as causes or contributing factors in over half of all accidents. A similar observation has been made in nuclear power plants. Yet laboratory research on decision making has not proven especially helpful in improving the quality of decisions in these kinds of environments. One reason is that the traditional, analytic decision models are inappropriate to multidimensional, high-risk environments, and do not accurately describe what expert human decision makers do when they make decisions that have consequences. A new model of dynamic, naturalistic decision making is offered that may prove useful for improving decision making in complex, isolated, confined and high-risk environments. Based on analyses of crew performance in full-mission simulators and accident reports, features that define effective decision strategies in abnormal or emergency situations have been identified. These include accurate situation assessment (including time and risk assessment), appreciation of the complexity of the problem, sensitivity to constraints on the decision, timeliness of the response, and use of adequate information. More effective crews also manage their workload to provide themselves with time and resources to make good decisions. In brief, good decisions are appropriate to the demands of the situation. Effective crew decision making and overall performance are mediated by crew communication. Communication
Russ, Alissa L; Militello, Laura G; Glassman, Peter A; Arthur, Karen J; Zillich, Alan J; Weiner, Michael
Cognitive task analysis (CTA) can yield valuable insights into healthcare professionals' cognition and inform system design to promote safe, quality care. Our objective was to adapt CTA-the critical decision method, specifically-to investigate patient safety incidents, overcome barriers to implementing this method, and facilitate more widespread use of cognitive task analysis in healthcare. We adapted CTA to facilitate recruitment of healthcare professionals and developed a data collection tool to capture incidents as they occurred. We also leveraged the electronic health record (EHR) to expand data capture and used EHR-stimulated recall to aid reconstruction of safety incidents. We investigated 3 categories of medication-related incidents: adverse drug reactions, drug-drug interactions, and drug-disease interactions. Healthcare professionals submitted incidents, and a subset of incidents was selected for CTA. We analyzed several outcomes to characterize incident capture and completed CTA interviews. We captured 101 incidents. Eighty incidents (79%) met eligibility criteria. We completed 60 CTA interviews, 20 for each incident category. Capturing incidents before interviews allowed us to shorten the interview duration and reduced reliance on healthcare professionals' recall. Incorporating the EHR into CTA enriched data collection. The adapted CTA technique was successful in capturing specific categories of safety incidents. Our approach may be especially useful for investigating safety incidents that healthcare professionals "fix and forget." Our innovations to CTA are expected to expand the application of this method in healthcare and inform a wide range of studies on clinical decision making and patient safety.
Mokhles, S; Nuyttens, J J M E; de Mol, M; Aerts, J G J V; Maat, A P W M; Birim, Ö; Bogers, A J J C; Takkenberg, J J M
The objective of this study is to investigate the role and experience of early stage non-small cell lung cancer (NSCLC) patient in decision making process concerning treatment selection in the current clinical practice. Stage I-II NSCLC patients (surgery 55 patients, SBRT 29 patients, median age 68) were included in this prospective study and completed a questionnaire that explored: (1) perceived patient knowledge of the advantages and disadvantages of the treatment options, (2) experience with current clinical decision making, and (3) the information that the patient reported to have received from their treating physician. This was assessed by multiple-choice, 1-5 Likert Scale, and open questions. The Decisional Conflict Scale was used to assess the decisional conflict. Health related quality of life (HRQoL) was measured with SF-36 questionnaire. In 19% of patients, there was self-reported perceived lack of knowledge about the advantages and disadvantages of the treatment options. Seventy-four percent of patients felt that they were sufficiently involved in decision-making by their physician, and 81% found it important to be involved in decision making. Forty percent experienced decisional conflict, and one-in-five patients to such an extent that it made them feel unsure about the decision. Subscores with regard to feeling uninformed and on uncertainty, contributed the most to decisional conflict, as 36% felt uninformed and 17% of patients were not satisfied with their decision. HRQoL was not influenced by patient experience with decision-making or patient preferences for shared decision making. Dutch early-stage NSCLC patients find it important to be involved in treatment decision making. Yet a substantial proportion experiences decisional conflict and feels uninformed. Better patient information and/or involvement in treatment-decision-making is needed in order to improve patient knowledge and hopefully reduce decisional conflict.
Full Text Available Maureen Reni Courtney,1 Christy Spivey,2 Kathy M Daniel1 1College of Nursing, 2College of Business, University of Texas at Arlington, Arlington, TX, USA Abstract: Clinicians are committed to effectively educating patients and helping them to make sound decisions concerning their own health care. However, how do clinicians determine what is effective education? How do they present information clearly and in a manner that patients understand and can use to make informed decisions? Behavioral economics (BE is a subfield of economics that can assist clinicians to better understand how individuals actually make decisions. BE research can help guide interactions with patients so that information is presented and discussed in a more deliberate and impactful way. We can be more effective providers of care when we understand the factors that influence how our patients make decisions, factors of which we may have been largely unaware. BE research that focuses on health care and medical decision making is becoming more widely known, and what has been reported suggests that BE interventions can be effective in the medical realm. The purpose of this article is to provide clinicians with an overview of BE decision science and derived practice strategies to promote more effective behavior change in patients.Keywords: nursing, message framing, defaults, incentives, social norms, commitment devices, health care
Adepoju, Ibukun-Oluwa Omolade; Albersen, Bregje Joanna Antonia; De Brouwere, Vincent; van Roosmalen, Jos; Zweekhorst, Marjolein
In a bid to deliver quality health services in resource-poor settings, mobile health (mHealth) is increasingly being adopted. The role of mHealth in facilitating evidence-based clinical decision-making through data collection, decision algorithms, and evidence-based guidelines, for example, is established in resource-rich settings. However, the extent to which mobile clinical decision support systems (mCDSS) have been adopted specifically in resource-poor settings such as Africa and the lessons learned about their use in such settings are yet to be established. The aim of this study was to synthesize evidence on the use of mHealth for point-of-care decision support and improved quality of care by health care workers in Africa. A scoping review of 4 peer-reviewed and 1 grey literature databases was conducted. No date limits were applied, but only articles in English language were selected. Using pre-established criteria, 2 reviewers screened articles and extracted data. Articles were analyzed using Microsoft Excel and MAXQDA. We retained 22 articles representing 11 different studies in 7 sub-Saharan African countries. Interventions were mainly in the domain of maternal health and ranged from simple text messaging (short message service, SMS) to complex multicomponent interventions. Although health workers are generally supportive of mCDSS and perceive them as useful, concerns about increased workload and altered workflow hinder sustainability. Facilitators and barriers to use of mCDSS include technical and infrastructural support, ownership, health system challenges, and training. The use of mCDSS in sub-Saharan Africa is an indication of progress in mHealth, although their effect on quality of service delivery is yet to be fully explored. Lessons learned are useful for informing future research, policy, and practice for technologically supported health care delivery, especially in resource-poor settings. ©Ibukun-Oluwa Omolade Adepoju, Bregje Joanna Antonia
See, A.; Johansen, J.; Hamilton, C.; Bydder, S.A.; Hawkins, J.; Roff, M.; Denham, J.; Kron, T.
Portal films continue to play an important role in the verification of radiotherapy treatment. There is still some discussion, however, as to what action should be taken after a port film has shown a radiation field deviation from the prescribed volume. It was the aim of the present pilot study to investigate the performance of three decision-making models ('Amsterdam', 'Quebec' and 'Newcastle') and an expert panel basing their decision on intuition rather than formal rules after portal film acquisition in a clinical setting. Portal films were acquired on every day during the first week of treatment for five head and neck and five prostate cancer patients (diagnostic phase). If required, the field position was modified according to our normal practice following the recommendation of the expert panel. In order to analyse the results of the models, however, additional port films were taken in the following 3 treatment weeks with the patient moved as required by the different models (intervention phase). The portal films were taken over 4 consecutive days, positioning the patient according to each of the different models on one day each. None of the models diagnosed a field misplacement in the head and neck patients, while the 'Amsterdam' and 'Quebec' models predicted a move in one prostate patient. The 'Newcastle' model, which is based on Hotelling's T 2 statistic, proved to be more sensitive and diagnosed a systematic displacement for three prostate patients. The intervention phase confirmed the diagnosis of the model, even if the three portal films taken with the patient position adjusted as required by the model proved to be insufficient to demonstrate an improvement. The 'Newcastle' model does not rely on assumptions about the random movement of patients and requires five portal films before a decision can be reached. This approach lends itself well to incorporation into electronic portal imaging 'packages', where repeated image acquisitions present no logistical
Danielson, Carla Kmett; Cohen, Joseph R; Adams, Zachary W; Youngstrom, Eric A; Soltis, Kathryn; Amstadter, Ananda B; Ruggiero, Kenneth J
The present study aimed to utilize a Receiver Operating Characteristic (ROC) approach in order to improve clinical decision-making for adolescents at risk for the development of psychopathology in the aftermath of a natural disaster. Specifically we assessed theoretically-driven individual, interpersonal, and event-related vulnerability factors to determine which indices were most accurate in forecasting PTSD. Furthermore, we aimed to translate these etiological findings by identifying clinical cut-off recommendations for relevant vulnerability factors. Our study consisted of structured phone-based clinical interviews with 2000 adolescent-parent dyads living within a 5-mile radius of tornados that devastated Joplin, MO, and northern Alabama in Spring 2011. Demographics, tornado incident characteristics, prior trauma, mental health, and family support and conflict were assessed. A subset of youth completed two behavioral assessment tasks online to assess distress tolerance and risk-taking behavior. ROC analyses indicated four variables that significantly improved PTSD diagnostic efficiency: Lifetime depression (AUC = .90), trauma history (AUC = .76), social support (AUC = .70), and family conflict (AUC = .72). Youth were 2-3 times more likely to have PTSD if they had elevated scores on any of these variables. Of note, event-related characteristics (e.g., property damage) were not related to PTSD diagnostic status. The present study adds to the literature by making specific recommendations for empirically-based, efficient disaster-related PTSD assessment for adolescents following a natural disaster. Implications for practice and future trauma-related developmental psychopathology research are discussed.
Lee, Daphne Sk; Abdullah, Khatijah Lim; Subramanian, Pathmawathi; Bachmann, Robert Thomas; Ong, Swee Leong
To explore whether there is a correlation between critical thinking ability and clinical decision-making among nurses. Critical thinking is currently considered as an essential component of nurses' professional judgement and clinical decision-making. If confirmed, nursing curricula may be revised emphasising on critical thinking with the expectation to improve clinical decision-making and thus better health care. Integrated literature review. The integrative review was carried out after a comprehensive literature search using electronic databases Ovid, EBESCO MEDLINE, EBESCO CINAHL, PROQuest and Internet search engine Google Scholar. Two hundred and 22 articles from January 1980 to end of 2015 were retrieved. All studies evaluating the relationship between critical thinking and clinical decision-making, published in English language with nurses or nursing students as the study population, were included. No qualitative studies were found investigating the relationship between critical thinking and clinical decision-making, while 10 quantitative studies met the inclusion criteria and were further evaluated using the Quality Assessment and Validity Tool. As a result, one study was excluded due to a low-quality score, with the remaining nine accepted for this review. Four of nine studies established a positive relationship between critical thinking and clinical decision-making. Another five studies did not demonstrate a significant correlation. The lack of refinement in studies' design and instrumentation were arguably the main reasons for the inconsistent results. Research studies yielded contradictory results as regard to the relationship between critical thinking and clinical decision-making; therefore, the evidence is not convincing. Future quantitative studies should have representative sample size, use critical thinking measurement tools related to the healthcare sector and evaluate the predisposition of test takers towards their willingness and ability to think
Full Text Available Background Conventional dentures in edentulous patients show some limitations due to the lack of retention, support and stability thus resulting in difficulty to chew. The modern implantology allows to use different implant overdentures and different attachment systems. The selection of the attachment by practitioners is mainly influenced by the clinical experience or technical preferences. Aims The aim of the present review is to provide an adequate background to the clinicians, in order to select the prosthetic attachments according to the current literature. The mechanical attachments have been compared to the magnetic devices, with the aim to guide the decision of the practitioners. Methods Articles topics selection was based on the use of magnetic attachments in dentistry and the comparison between them and mechanical connectors. The databases used were PubMed/MEDLINE, Google Scholar and ISI Web of Science. A critical evaluation of the selected paper has been made to choose the ones that matched the inclusion criteria. Results Nowadays, few studies have compared different attachments in a manner useful for clinical decision-making. The main problem limiting long-term durability of magnetic attachments in the oral fluid is the poor corrosion resistance of permanent magnets and the consequent leaching of cytotoxic ions. Conclusion Magnetic attachments in comparison with other attaching systems can be useful in patients with special needs, in patients with limited interocclusal space, or in patients with neuromuscular limitations, thanks to the automatic reseating properties. However, it’s important to highlight that the mechanical attachments still represent the best choice in common conditions requiring dental prostheses.
Thompson, Steven; Varvel, Stephen; Sasinowski, Maciek; Burke, James P
Big data and advances in analytical processes represent an opportunity for the healthcare industry to make better evidence-based decisions on the value generated by various tests, procedures, and interventions. Value-based reimbursement is the process of identifying and compensating healthcare providers based on whether their services improve quality of care without increasing cost of care or maintain quality of care while decreasing costs. In this article, we motivate and illustrate the potential opportunities for payers and providers to collaborate and evaluate the clinical and economic efficacy of different healthcare services. We conduct a case study of a firm that offers advanced biomarker and disease state management services for cardiovascular and cardiometabolic conditions. A value-based analysis that comprised a retrospective case/control cohort design was conducted, and claims data for over 7000 subjects who received these services were compared to a matched control cohort. Study subjects were commercial and Medicare Advantage enrollees with evidence of CHD, diabetes, or a related condition. Analysis of medical claims data showed a lower proportion of patients who received biomarker testing and disease state management services experienced a MI (p companies have in terms of identifying value-creating healthcare interventions. However, payers and providers also need to pursue system integration efforts to further automate the identification and dissemination of clinically and economically efficacious treatment plans to ensure at-risk patients receive the treatments and interventions that will benefit them the most.
Jayanti, Anuradha; Neuvonen, Markus; Wearden, Alison; Morris, Julie; Foden, Philip; Brenchley, Paul; Mitra, Sandip
Medical decision-making is critical to patient survival and well-being. Patients with end stage renal disease (ESRD) are faced with incrementally complex decision-making throughout their treatment journey. The extent to which patients seek involvement in the decision-making process and factors which influence these in ESRD need to be understood. 535 ESRD patients were enrolled into the cross-sectional study arm and 30 patients who started dialysis were prospectively evaluated. Patients were enrolled into 3 groups- 'predialysis' (group A), 'in-centre' haemodialysis (HD) (group B) and self-care HD (93 % at home-group C) from across five tertiary UK renal centres. The Autonomy Preference Index (API) has been employed to study patient preferences for information-seeking (IS) and decision-making (DM). Demographic, psychosocial and neuropsychometric assessments are considered for analyses. 458 complete responses were available. API items have high internal consistency in the study population (Cronbach's alpha > 0.70). Overall and across individual study groups, the scores for information-seeking and decision-making are significantly different indicating that although patients had a strong preference to be well informed, they were more neutral in their preference to participate in DM (p gender, marital status; higher API IS scores and white ethnicity background were significant predictors of preference for decision-making. DM scores were subdivided into tertiles to identify variables associated with high (DM > 70: and low DM (≤30) scores. This shows association of higher DM scores with lower age, lower comorbidity index score, higher executive brain function, belonging in the self-caring cohort and being unemployed. In the prospectively studied cohort of predialysis patients, there was no change in decision-making preference scores after commencement of dialysis. ESRD patients prefer to receive information, but this does not always imply active involvement in
Elwyn, G; Edwards, A; Wensing, M; Hibbs, R; Wilkinson, C; Grol, R
The aim of the study was to examine the communication strategies of general practitioners attempting to involve patients in treatment or management decisions. This empirical data was then compared with theoretical 'competences' derived for 'shared decision making'. The subjects were four general practitioners, who taped conducted consultations with the specific intent of involving patients in the decision-making process. The consultations were transcribed, coded into skill categorizations and presented as visual display using a specifically devised sequential banding The empirical data from these purposively selected consultation from clinicians who are experienced in shared decision making did not match suggested theoretical frameworks. The views of patients about treatment possibilities and their preferred role in decision making were not explored. The interactions were initiated by a problem-defining phase, statements of 'equipoise' consistently appeared and the portrayal of option information was often intermingled with opportunities to allow patients to question and reflect. A decision-making stage occurred consistently after approximately 80% of the total consultation duration and arrangements were consistently made for follow-up and review. Eight of the 10 consultations took more than 11 min - these specific consultations were characterized by significant proportions of time provided for information exchange and patient interaction. The results demonstrate that some theoretical competences are not distinguishable in practice and other stages, not previously described, such as the 'portrayal of equipoise', are observed. The suggested ideal of a shared decision-making interaction will either require more time than currently allocated, or alternative strategies to enable information exchange outside the consultation.
The self-centeredness of modern organizations leads to environmental destruction and human deprivation. The principle of responsibility developed by Hans Jonas requires caring for the beings affected by our decisions and actions. Ethical decision-making creates a synthesis of reverence for ethical norms, rationality in goal achievement, and respect for the stakeholders. The maximin rule selects the "least worst alternative" in the multidimensional decision space of deontologica...
Jain, Lakhmi C
The present "Volume 1: Techniques and Applications" of the "Handbook on Decision Making" presents a useful collection of AI techniques, as well as other complementary methodologies, that are useful for the design and development of intelligent decision support systems. Application examples of how these intelligent decision support systems can be utilized to help tackle a variety of real-world problems in different domains, such as business, management, manufacturing, transportation and food industries, and biomedicine, are presented. The handbook includes twenty condensed c
Stokman, Frans N.; Assen, Marcel A.L.M. van; Knoop, Jelle van der; Oosten, Reinier C.H. van
This paper introduces a methodology for strategic intervention in collective decision making.The methodology is based on (1) a decomposition of the problem into a few main controversial issues, (2) systematic interviews of subject area specialists to obtain a specification of the decision
Hagmayer, York; Meder, Bjorn
Many of our decisions refer to actions that have a causal impact on the external environment. Such actions may not only allow for the mere learning of expected values or utilities but also for acquiring knowledge about the causal structure of our world. We used a repeated decision-making paradigm to examine what kind of knowledge people acquire in…
Jonassen, David H.
Decision making is the most common kind of problem solving. It is also an important component skill in other more ill-structured and complex kinds of problem solving, including policy problems and design problems. There are different kinds of decisions, including choices, acceptances, evaluations, and constructions. After describing the centrality…
Fitzgerald, Anneke; Wu, Yong
Objective This paper describes the perceptions of operating theatre staff in Australia and The Netherlands regarding the influence of logistical or operational reasons that may affect the scheduling of unplanned surgical cases. It is proposed that logistical or operational issues can influence the priority determination of queue position of surgical cases on the emergency waiting list. Methods A questionnaire was developed and conducted in 15 hospitals across The Netherlands and Australia, targeting anaesthetists, managers, nurses and surgeons. Statistical analyses revolved around these four professional groups. Six hypotheses were then developed and tested based on the responses collected from the participants. Results There were significant differences in perceptions of logistics delay factors across different professional groups when patients were waiting for unplanned surgery. There were also significant differences among different groups when setting logistical priority factors for planning and scheduling unplanned cases. The hypotheses tests confirm these differences, and the findings concur with the paradigmatic differences mentioned in the literature. These paradigmatic differences among the four professional groups may explain some of the tensions encountered when making decisions about scheduling emergency surgical queues, and therefore should be taken into consideration for management of operating theatres. Conclusions Queue positions of patients waiting for unplanned surgery, or emergency surgery, are determined by medical clinicians according to clinicians' indication of clinical priority. However, operating theatre managers are important in facilitating smooth operations when planning for emergency surgeries. It is necessary for surgeons to understand the logistical challenges faced by managers when requesting logistical priorities for their operations. What is known about the topic? Tensions exist about the efficient use of operating theatres and
Lerner, Jennifer S; Li, Ye; Valdesolo, Piercarlo; Kassam, Karim S
A revolution in the science of emotion has emerged in recent decades, with the potential to create a paradigm shift in decision theories. The research reveals that emotions constitute potent, pervasive, predictable, sometimes harmful and sometimes beneficial drivers of decision making. Across different domains, important regularities appear in the mechanisms through which emotions influence judgments and choices. We organize and analyze what has been learned from the past 35 years of work on emotion and decision making. In so doing, we propose the emotion-imbued choice model, which accounts for inputs from traditional rational choice theory and from newer emotion research, synthesizing scientific models.
Mellers, B A; Schwartz, A; Cooke, A D
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.
Lauesen, Linne Marie
of the interaction between a corporation and its stakeholders. Methodology/approach: This paper offers a theoretical 'Organic Stakeholder Model' based on decision making theory, risk assessment and adaption to a rapidly changing world combined with appropriate stakeholder theory for ethical purposes in decision...... applicable): The Model is based on case studies, but the limited scope of the length of the paper did not leave room to show the empirical evidence, but only the theoretical study. Originality / value of a paper: The model offers a new way of combining risk management with ethical decision-making processes...... by the inclusion of multiple stakeholders. The conceptualization of the model enhances business ethics in decision making by managing and balancing stakeholder concerns with the same concerns as the traditional risk management models does – for the sake of the wider social responsibilities of the businesses...
Witt, Claudia M; Huang, Wen-jing; Lao, Lixing; Berman, Brian M
In clinical research on complementary and integrative medicine, experts and scientists have often pursued a research agenda in spite of an incomplete understanding of the needs of end users. Consequently, the majority of previous clinical trials have mainly assessed the efficacy of interventions. Scant data is available on their effectiveness. Comparative effectiveness research (CER) promises to support decision makers by generating evidence that compares the benefits and harms of best care options. This evidence, more generalizable than evidence generated by traditional randomized clinical trials (RCTs), is better suited to inform real-world care decisions. An emphasis on CER supports the development of the evidence base for clinical and policy decision-making. Whereas in most areas of complementary and integrative medicine data on CER is scarce, available acupuncture research already contributes to CER evidence. This paper will introduce CER and make suggestions for future research.
Ameneiros-Lago, E; Carballada-Rico, C; Garrido-Sanjuán, J A; García Martínez, A
Decision making in the patient with chronic advanced disease is especially complex. Health professionals are obliged to prevent avoidable suffering and not to add any more damage to that of the disease itself. The adequacy of the clinical interventions consists of only offering those diagnostic and therapeutic procedures appropriate to the clinical situation of the patient and to perform only those allowed by the patient or representative. In this article, the use of an algorithm is proposed that should serve to help health professionals in this decision making process. Copyright © 2014 SECA. Published by Elsevier Espana. All rights reserved.
Full Text Available Pulmonary embolism (PE is a common disease with a not negligible short-term risk of death, in particular in the elderly. An adequate evaluation of the prognosis in patients with PE may guide decision-making in terms of the intensity of the initial treatment during the acute phase. Patients with shock or persistent hypotension are at high risk of early mortality and may benefit from immediate reperfusion. Several tools are available to define the short-term prognosis of hemodynamically stable patients. The pulmonary embolism severity index (PESI score, and the simplified PESI score are particularly useful for identifying patients at low risk of early complications who might be safely treated at home. The identification of patients who are hemodynamically stable at diagnosis but are at a high risk of early complications is more challenging. Current guidelines recommend a multi-parametric prognostic algorithm based on the clinical status, biomarkers and imaging tests. However an aggressive treatment in hemodynamically stable patients is still controversial.
Fuller, Shannon M; Koester, Kimberly A; Guinness, Ryan R; Steward, Wayne T
Shared decision-making (SDM) is considered best practice in health care. Prior studies have explored attitudes and barriers/facilitators to SDM, with few specific to HIV care. We interviewed 53 patients in HIV primary care clinics in California to understand the factors and situations that may promote or hinder engagement in SDM. Studies in other populations have found that patients' knowledge about their diseases and their trust in providers facilitated SDM. We found these features to be more nuanced for HIV. Perceptions of personal agency, knowledge about one's disease, and trust in provider were factors that could work for or against SDM. Overall, we found that participants described few experiences of SDM, especially among those with no comorbidities. Opportunities for SDM in routine HIV care (e.g., determining antiretroviral therapy) may arise infrequently because of treatment advances. These findings yield considerations for adapting SDM to fit the context of HIV care. Copyright © 2016 The Authors. Published by Elsevier Inc. All rights reserved.
Berggren, Ingela; Severinsson, Elisabeth
The aim of the study was to explore the decision-making style and ethical approach of nurse supervisors by focusing on their priorities and interventions in the supervision process. Clinical supervision promotes ethical awareness and behaviour in the nursing profession. A focus group comprised of four clinical nurse supervisors with considerable experience was studied using qualitative hermeneutic content analysis. The essence of the nurse supervisors' decision-making style is deliberations and priorities. The nurse supervisors' willingness, preparedness, knowledge and awareness constitute and form their way of creating a relationship. The nurse supervisors' ethical approach focused on patient situations and ethical principles. The core components of nursing supervision interventions, as demonstrated in supervision sessions, are: guilt, reconciliation, integrity, responsibility, conscience and challenge. The nurse supervisors' interventions involved sharing knowledge and values with the supervisees and recognizing them as nurses and human beings. Nurse supervisors frequently reflected upon the ethical principle of autonomy and the concept and substance of integrity. The nurse supervisors used an ethical approach that focused on caring situations in order to enhance the provision of patient care. They acted as role models, shared nursing knowledge and ethical codes, and focused on patient related situations. This type of decision-making can strengthen the supervisees' professional identity. The clinical nurse supervisors in the study were experienced and used evaluation decisions as their form of clinical decision-making activity. The findings underline the need for further research and greater knowledge in order to improve the understanding of the ethical approach to supervision.
The study of judgment and decision making entails three interrelated forms of research: (1) normative analysis, identifying the best courses of action, given decision makers' values; (2) descriptive studies, examining actual behavior in terms comparable to the normative analyses; and (3) prescriptive interventions, helping individuals to make better choices, bridging the gap between the normative ideal and the descriptive reality. The research is grounded in analytical foundations shared by economics, psychology, philosophy, and management science. Those foundations provide a framework for accommodating affective and social factors that shape and complement the cognitive processes of decision making. The decision sciences have grown through applications requiring collaboration with subject matter experts, familiar with the substance of the choices and the opportunities for interventions. Over the past half century, the field has shifted its emphasis from predicting choices, which can be successful without theoretical insight, to understanding the processes shaping them. Those processes are often revealed through biases that suggest non-normative processes. The practical importance of these biases depends on the sensitivity of specific decisions and the support that individuals have in making them. As a result, the field offers no simple summary of individuals' competence as decision makers, but a suite of theories and methods suited to capturing these sensitivities. Copyright © 2010 John Wiley & Sons, Ltd. For further resources related to this article, please visit the WIREs website. Copyright © 2010 John Wiley & Sons, Ltd.
Mena, I.G.; Strauss, H.W.
This report contains ten papers on the use of noninvasive imaging in clinical diagnosis and decision making. Topics include a cost analysis of magnetic resonance imaging in medical technology, diagnostic uses of MRI in chronic coronary artery disease, clinical applications of cine computed tomography, the use of PET as a clinical tool, and the use of echocardiography in coronary artery disease. Individual papers are processed separately for the data base
Smith, Grace L; Smith, Benjamin D
In older patients, radiation treatment plays a vital role in curative and palliative cancer therapy. Radiation treatment recommendations should be informed by a comprehensive, personalized risk-benefit assessment that evaluates treatment efficacy and toxicity. We review several clinical factors that distinctly affect efficacy and toxicity of radiation treatment in older patients. First, locoregional tumor behavior may be more indolent in older patients for some disease sites but more aggressive for other sites. Assessment of expected locoregional relapse risk informs the magnitude and timeframe of expected radiation treatment benefits. Second, assessment of the competing cancer versus noncancer mortality and morbidity risks contextualizes cancer treatment priorities holistically within patients' entire spectrum and time course of health needs. Third, assessment of functional reserve helps predict patients' acute treatment tolerance, differentiating those patients who are unlikely to benefit from treatment or who are at high risk for treatment complications. Potential radiation treatment options include immediate curative treatment, delayed curative treatment, and no treatment, with additional consideration given to altered radiation target, dose, or sequencing with chemotherapy and/or surgery. Finally, when cure is not feasible, palliative radiation therapy remains valuable for managing symptoms and achieving meaningful quality-of-life improvements. Our proposed decision-making framework integrates these factors to help radiation oncologists formulate strategic treatment recommendations within a multidisciplinary context. Future research is still needed to identify how advanced technologies can be judiciously applied in curative and palliative settings to enhance risk-benefit profiles of radiation treatment in older patients and more accurately quantify treatment efficacy in this group. © 2014 by American Society of Clinical Oncology.
Weed, L L; Zimny, N J
The information tool to aid us in making the clinical decisions discussed in this presentation is called the PKC. Our goal with patients should be to couple the knowledge of the unique patient to the knowledge in the literature and get the best possible match. This approach requires combinatorial versus probabilistic thinking. In the real world, ideal matches are not found. Therefore, it is critical to exhaust the patient's uniqueness first and only then use probabilities to settle further uncertainties. It is an error to teach people how to deal with uncertainty instead of teaching them to clean up a great deal of the uncertainty first. Patients must be involved in this endeavor. In essence, they have a PhD in their own uniqueness, and it is this uniqueness that is very powerful in solving complex problems. This method of patient evaluation and management cannot be used with the unaided mind. It requires new and powerful information tools like the PKC. All information that is relevant to a problem should be included in the coupler. It should encompass differing points of view, and the rationale should be made explicit to clinician and patient alike. When complete, the coupler should represent an interdisciplinary compilation of questions and tests that are expected to be collected every time in the clinic for the type of problem the coupler represents. This method will provide a basis for quality control because the contents of the coupler now have defined what we expect to occur in every patient encounter.(ABSTRACT TRUNCATED AT 250 WORDS)
Seçil Arslansoyu Çamlar
Full Text Available Hydronephrosis may be related to an obstructive cause, ureteropelvic/uretero-vesical junction obstruction or nonobstructive [vesicoureteral reflux (VUR]. When an obstructive pathology is considered, dynamic renal scintigraphy may help to predict whether it is a true obstruction or not. In this study, we aimed to determine the contribution of dynamic renal scintigraphy with  mTc-MAG-3 to the clinical decision-making for surgery in hydronephrotic children. Files of the patients evaluated by MAG-3 scintigraphy for antenatal (AH/postnatal (PH hydronephrosis between 1992 and 2014 were reviewed. Gender, age, hydronephrosis (HN grade by ultrasound (US, presence of VUR, MAG-3 result (obstructive vs. nonobstructive, ultimate diagnosis, and need for surgery were assessed. Cases with double collecting system and neurogenic bladder were excluded from the study. All of the patients had normal serum creatinine and eGFR. There were a total of 178 patients with 218 hydronephrotic renal units (mean age 34.7 ± 52.7 months; male/ female = 121/57, AH of 62%. MAG-3 was nonobstructive in 134 and obstructive in 84 hydronephrotic renal units. MAG-3 was obstructive in 47 of 121 (39% males and 30 of 57 (53% females (P = 0.058, odds ratio (OR for obstruction was 1.9 for girls. MAG-3 was obstructive in 47 of 135 (35% units with AH and 37 of 83 (45% units with PH (P = 0.137. In 81 units with the society of fetal urology-4 HN by US, MAG-3 was obstructive in 55 (68%, and surgery was required in 52 of 55 (95%. Surgery was required for only two (7% of the remaining 26 units with nonobstructive dilatation (P 16.5 mm was the best cutoff level for predicting obstruction by MAG-3 (sensitivity 75.2%; specificity 71%; OR 3.8. MAG-3 significantly affects clinical decision for surgery in HN. Hydronephrotic girls have more risk in terms of true obstruction. Combining MAG-3 with US improves the discrimination of true obstruction during follow-up.
Hagmayer, York; Meder, Björn
Many of our decisions refer to actions that have a causal impact on the external environment. Such actions may not only allow for the mere learning of expected values or utilities but also for acquiring knowledge about the causal structure of our world. We used a repeated decision-making paradigm to examine what kind of knowledge people acquire in such situations and how they use their knowledge to adapt to changes in the decision context. Our studies show that decision makers' behavior is strongly contingent on their causal beliefs and that people exploit their causal knowledge to assess the consequences of changes in the decision problem. A high consistency between hypotheses about causal structure, causally expected values, and actual choices was observed. The experiments show that (a) existing causal hypotheses guide the interpretation of decision feedback, (b) consequences of decisions are used to revise existing causal beliefs, and (c) decision makers use the experienced feedback to induce a causal model of the choice situation even when they have no initial causal hypotheses, which (d) enables them to adapt their choices to changes of the decision problem. (PsycINFO Database Record (c) 2013 APA, all rights reserved).
Stokman, Frans N.; Assen, Marcel A.L.M. van; Knoop, Jelle van der; Oosten, Reinier C.H. van
This paper introduces a methodology for strategic intervention in collective decision making.The methodology is based on (1) a decomposition of the problem into a few main controversial issues, (2) systematic interviews of subject area specialists to obtain a specification of the decision setting,consisting of a list of stakeholders with their capabilities, positions, and salience on each of the issues; (3) computer simulation. The computer simulation models incorporate only the main processe...
This article presents evidence that the potential loss of control of events by officials who must operate under conditions that generate substantial stress is one of the central problems of crisis decision making. Examples of U.S. crises management and alliance management are reviewed, and possible tools for improving crisis management decisions are discussed. This article particularly focuses on crises which may lead to nuclear war
Witt, Claudia M; Huang, Wen-jing; Lao, Lixing; Bm, Berman
In clinical research on complementary and integrative medicine, experts and scientists have often pursued a research agenda in spite of an incomplete understanding of the needs of end users. Consequently, the majority of previous clinical trials have mainly assessed the efficacy of interventions. Scant data is available on their effectiveness. Comparative effectiveness research (CER) promises to support decision makers by generating evidence that compares the benefits and harms of the best care options. This evidence, more generalizable than the evidence generated by traditional randomized controlled trials (RCTs), is better suited to inform real-world care decisions. An emphasis on CER supports the development of the evidence base for clinical and policy decision-making. Whereas in most areas of complementary and integrative medicine data on comparative effectiveness is scarce, available acupuncture research already contributes to CER evidence. This paper will introduce CER and make suggestions for future research.
Gorini, Alessandra; Mazzocco, Ketti; Pravettoni, Gabriella
Due to the lack of other treatment options, patient candidates for participation in phase I clinical trials are considered the most vulnerable, and many ethical concerns have emerged regarding the informed consent process used in the experimental design of such trials. Starting with these considerations, this nonsystematic review is aimed at analyzing the decision-making processes underlying patients' decision about whether to participate (or not) in phase I trials in order to clarify the cognitive and emotional aspects most strongly implicated in this decision. Considering that there is no uniform decision calculus and that many different variables other than the patient-physician relationship (including demographic, clinical, and personal characteristics) may influence patients' preferences for and processing of information, we conclude that patients' informed decision-making can be facilitated by creating a rigorously developed, calibrated, and validated computer tool modeled on each single patient's knowledge, values, and emotional and cognitive decisional skills. Such a tool will also help oncologists to provide tailored medical information that is useful to improve the shared decision-making process, thereby possibly increasing patient participation in clinical trials. © 2015 S. Karger AG, Basel.
The fundamental objective of all nuclear safety regulatory bodies is to ensure that nuclear utilities operate their plants at all times in an acceptably safe manner. In meeting this objective, the regulatory body should strive to ensure that its regulatory decisions are technically sound, consistent from case to case, and timely. In addition, the regulator must be aware that its decisions and the circumstances surrounding those decisions can affect how its stakeholders, such as government policy makers, the industry it regulates, and the public, view it as an effective and credible regulator. In order to maintain the confidence of those stakeholders, the regulator should make sure that its decisions are transparent, have a clear basis in law and regulations, and are seen by impartial observers to be fair to all parties. Based on the work of a Nuclear Energy Agency (NEA) expert group, this report discusses some of the basic principles and criteria that a regulatory body should consider in making decisions and describes the elements of an integrated framework for regulatory decision making. (author)
Wieland, Patricia; Almeida, Ivan Pedro Salati de
The scientific considerations upon which the nuclear regulations are based provide objective criteria for decisions on nuclear safety matters. However, the decisions that a regulatory agency takes go far beyond granting or not an operating license based on assessment of compliance. It may involve decisions about hiring experts or research, appeals, responses to other government agencies, international agreements, etc.. In all cases, top management of the regulatory agency should hear and decide the best balance between the benefits of regulatory action and undue risks and other associated impacts that may arise, including issues of credibility and reputation. The establishment of a decision framework based on well established principles and criteria ensures performance stability and consistency, preventing individual subjectivity. This article analyzes the challenges to the decision-making by regulatory agencies to ensure coherence and consistency in decisions, even in situations where there is uncertainty, lack of reliable information and even divergence of opinions among experts. The article explores the basic elements for a framework for regulatory decision-making. (author)
Karny, Miroslav; Wolpert, David
Decision making (DM) is ubiquitous in both natural and artificial systems. The decisions made often differ from those recommended by the axiomatically well-grounded normative Bayesian decision theory, in a large part due to limited cognitive and computational resources of decision makers (either artificial units or humans). This state of a airs is often described by saying that decision makers are imperfect and exhibit bounded rationality. The neglected influence of emotional state and personality traits is an additional reason why normative theory fails to model human DM process. The book is a joint effort of the top researchers from different disciplines to identify sources of imperfection and ways how to decrease discrepancies between the prescriptive theory and real-life DM. The contributions consider: · how a crowd of imperfect decision makers outperforms experts' decisions; · how to decrease decision makers' imperfection by reducing knowledge available; ...
Bouma, Berto J.; van den Brink, Renee B.; Zwinderman, K.; Cheriex, Emile C.; Hamer, Hans H.; Lie, Kong I.; Tijssen, Jan G.
Background and aim of the study: Clinical decision-making in an individual elderly patient with severe aortic stenosis (AS) is difficult. The prognosis is influenced by increased age and various cardiac morbidity and comorbidity, and the benefit of surgery is uncertain because the prognosis with
Blount, Kamilah V.
This study examined the impact of accelerated nursing direct entry master's programs on the development of clinical decision-making skills of new graduate nurses that completed the Performance Based Development System (PBDS) assessment during the study period of 2008-2012 at a healthcare organization. Healthcare today is practiced in a…
Maite Sara Mashego
Consensus decision making, concerns group members make decisions together with the requirement of reaching a consensus that is all members abiding by the decision outcome. Lone ranging worked for sometime in a autocratic environment. Researchers are now pointing to consensus decision-making in organizations bringing dividend to many organizations. This article used a descriptive analysis to compare the goodness of consensus decision making and making lone ranging decision management. This art...
Jacobs, Patricia A.
This report supplies references and comments on literature that identifies human factors influencing decision making, particularly military decision making. The literature has been classified as follows (the classes are not mutually exclusive): features of human information processing; decision making models which are not mathematical models but rather are descriptive; non- personality factors influencing decision making; national characteristics influencing decision makin...
Hurwitz, Lauren M; Cullen, Jennifer; Elsamanoudi, Sally; Kim, Daniel J; Hudak, Jane; Colston, Maryellen; Travis, Judith; Kuo, Huai-Ching; Porter, Christopher R; Rosner, Inger L
Patients diagnosed with prostate cancer (PCa) are presented with several treatment options of similar efficacy but varying side effects. Understanding how and why patients make their treatment decisions, as well as the effect of treatment choice on long-term outcomes, is critical to ensuring effective, patient-centered care. This study examined treatment decision-making in a racially diverse, equal-access, contemporary cohort of patients with PCa counseled on treatment options at a multidisciplinary clinic. A prospective cohort study was initiated at the Walter Reed National Military Medical Center (formerly Walter Reed Army Medical Center) in 2006. Newly diagnosed patients with PCa were enrolled before attending a multidisciplinary clinic. Patients completed surveys preclinic and postclinic to assess treatment preferences, reasons for treatment choice, and decisional regret. As of January 2014, 925 patients with PCa enrolled in this study. Surgery (54%), external radiation (20%), and active surveillance (12%) were the most common primary treatments for patients with low- and intermediate-risk PCa, whereas patients with high-risk PCa chose surgery (34%) or external radiation with neoadjuvant hormones (57%). Treatment choice differed by age at diagnosis, race, comorbidity status, and calendar year in both univariable and multivariable analyses. Patients preferred to play an active role in the decision-making process and cited doctors at the clinic as the most helpful source of treatment-related information. Almost all patients reported satisfaction with their decision. This is one of the first prospective cohort studies to examine treatment decision-making in an equal-access, multidisciplinary clinic setting. Studies of this cohort would aid in understanding and improving the PCa decision-making process. Published by Elsevier Inc.
HENDRIKS, MMWB; DEBOER, JH; SMILDE, AK; DOORNBOS, DA
Interest is growing in multicriteria decision making (MCDM) techniques and a large number of these techniques are now available. The purpose of this tutorial is to give a theoretical description of some of the MCDM techniques. Besides this we will give an overview of the differences and similarities
Anderson, J D; Jay, S J; Weng, H C; Anderson, M M
The influence of uncertainty on physicians' practice behavior is not well understood. In this research, ILIAD, a diagnostic expert system, has been used to study physicians' responses to uncertainty and how their responses affected clinical performance. The simulation mode of ILIAD was used to standardize the presentation and scoring of two cases to 46 residents in emergency medicine, internal medicine, family practice and transitional medicine at Methodist Hospital of Indiana. A questionnaire was used to collect additional data on how physicians respond to clinical uncertainty. A structural equation model was developed, estimated, and tested. The results indicate that stress that physicians experience in dealing with clinical uncertainty has a negative effect on their clinical performance. Moreover, the way that physicians respond to uncertainty has positive and negative effects on their performance. Open discussions with patients about clinical decisions and the use of practice guidelines improves performance. However, when the physician's clinical decisions are influenced by patient demands or their peers, their performance scores decline.
Dalke, Katharine Baratz; Wenzel, Amy; Kim, Deborah R
Depression and anxiety during pregnancy are common, and patients and providers are faced with complex decisions regarding various treatment modalities. A structured discussion of the risks and benefits of options with the patient and her support team is recommended to facilitate the decision-making process. This clinically focused review, with emphasis on the last 3 years of published study data, evaluates the major risk categories of medication treatments, namely pregnancy loss, physical malformations, growth impairment, behavioral teratogenicity, and neonatal toxicity. Nonpharmacological treatment options, including neuromodulation and psychotherapy, are also briefly reviewed. Specific recommendations, drawn from the literature and the authors' clinical experience, are also offered to help guide the clinician in decision-making.
Ingersgaard, Marianne Vie; Tulstrup, Morten; Schmiegelow, Kjeld
AIM: To explore parents' and adolescents' motives for accepting/declining participation in the ALL2008 trials and adolescents' involvement in the decision-making process. BACKGROUND: Children and adolescents with acute lymphoblastic leukaemia treated on the Nordic Society of Paediatric Haematology...... the adolescents' decision. There were no differences between motivations of preferences held by parents of children or adolescents, respectively. Decisions were based on subjective values attributed to cure contra toxicity and individual preferences for either standard or experimental treatment. The possibility....... FINDINGS: Adolescents and parents emphasized the importance of adolescents' active participation in decisions regarding enrolment into clinical trials. A majority of adolescents were either final or collaborative decision-makers. Parents stated that in case of disagreement, they would overrule...
Hostiuc, Sorin; Rusu, Mugurel Constantin; Negoi, Ionut; Drima, Eduard
The process of assessing the decision-making capacity of potential subjects before their inclusion in clinical trials is a legal requirement and a moral obligation, as it is essential for respecting their autonomy. This issue is especially important in psychiatry patients (such as those diagnosed with schizophrenia). The primary purpose of this article was to evaluate the degree of impairment in each dimension of decision-making capacity in schizophrenia patients compared to non-mentally-ill controls, as quantified by the (MacCAT-CR) instrument. Secondary objectives were (1) to see whether enhanced consent forms are associated with a significant increase in decision-making capacity in schizophrenia patients, and (2) if decision-making capacity in schizophrenia subjects is dependent on the age, gender, or the inpatient status of the subjects. We systematically reviewed the results obtained from three databases: ISI Web of Science, Pubmed, Scopus. Each database was scrutinised using the following keywords: "MacCAT-CR + schizophrenia", "decision-making capacity + schizophrenia", and "informed consent + schizophrenia." We included 13 studies in the analysis. The effect size between the schizophrenia and the control group was significant, with a difference in means of -4.43 (-5.76; -3.1, p reasoning, and -0.05 (-0.9, -0.01, p = 0.022) for expressing a choice. Even if schizophrenia patients have a significantly decreased decision-making capacity compared to non-mentally-ill controls, they should be considered as competent unless very severe changes are identifiable during clinical examination. Enhanced informed consent forms decrease the differences between schizophrenia patients and non-mentally-ill controls (except for the reasoning dimension) and should be used whenever the investigators want to include more ill patients in their clinical trials. Increased age, men gender and an increased percentage of inpatients might increase the differential of decision-making
Singh, Mandeep; Aung, Tin; Aquino, Maria C; Chew, Paul T K
To determine if imaging of blebs with anterior segment optical coherence tomography (ASOCT) affects clinical decision-making with regard to laser suture lysis (LSL) after trabeculectomy. In this prospective observational case series, we included patients with poorly controlled intraocular pressure (IOP) after standardized trabeculectomy from May to November 2006. One observer assessed IOP, anterior chamber depth and bleb formation, and recorded a decision of whether or not to undertake LSL based on clinical grounds. A second observer masked to clinical data recorded a decision of whether or not to perform LSL based on ASOCT assessment of scleral flap position, presence of a sub-flap space, patency of the internal ostium, and bleb wall thickening. We compared the 2 observers' decisions to determine how ASOCT influenced decision-making. Seven eyes of 7 patients were included. On the basis of clinical examination, LSL was recommended in all 7 (100.0%) cases due to presence of elevated IOP, deep anterior chambers and poorly formed blebs. Using ASOCT, LSL was recommended in 5/7 (71.4%) cases with apposed scleral flaps, absent sub-flap spaces, and absent bleb wall thickening. In 2/7 (28.7%) cases, LSL was not recommended based on ASOCT findings of an elevated scleral flap, a patent sub-flap space, and bleb wall thickening. All 7 patients had good IOP control and formed blebs at a mean of 8.4+/-2.6 months after trabeculectomy, with a mean IOP of 14.3+/-3.2 mm Hg with no medications. This small study suggests that ASOCT imaging may affect decision-making with regard to LSL by providing information not apparent on clinical examination.
This paper reports that the oil and gas business is undergoing a significant restructuring. In order to maintain control of our own destiny and succeed in an increasingly competitive business environment, the industry must set goals which are consistent with its continued success and focus on those goals in every aspect of its strategic management. By applying an approach to decision making which focuses on the achievement of the key goals required for success at every decision point and systematic follow-up, a firm can greatly increase its ability to succeed in the business environment of the future
Pedersen, Carsten Lund; Andersen, Torben Juul
, the aim of this study is to gain deeper insights into the complex and multifaceted decision processes that take place in large complex organizations operating in dynamic high-velocity markets. It is proposed that the ability to obtain faster, more accurate and updated insights about ongoing environmental......Strategic decision making remains a focal point in the strategy field, but despite decades of rich conceptual and empirical research we still seem distant from a level of understanding that can guide corporate practices effectively under turbulent and unpredictable environmental conditions. Hence...
Shared decision-making has been called the crux of patient-centred care and identified as a key part of change for improved quality and safety in healthcare. However, it rarely happens, is hard to do and is not taught - for many reasons. Talking with patients about options is not embedded in the attitudes or communication skills training of most healthcare professionals. Information tools such as patient decision aids, personal health records and the Internet will help to shift this state, as will policy that drives patient and public involvement in healthcare delivery and training.
Kumar, Amal; Chakraborty, Bhaswat S
Interim analysis of especially sizeable trials keeps the decision process free of conflict of interest while considering cost, resources, and meaningfulness of the project. Whenever necessary, such interim analysis can also call for potential termination or appropriate modification in sample size, study design, and even an early declaration of success. Given the extraordinary size and complexity today, this rational approach helps to analyze and predict the outcomes of a clinical trial that incorporate what is learned during the course of a study or a clinical development program. Such approach can also fill the gap by directing the resources toward relevant and optimized clinical trials between unmet medical needs and interventions being tested currently rather than fulfilling only business and profit goals.
Full Text Available Interim analysis of especially sizeable trials keeps the decision process free of conflict of interest while considering cost, resources, and meaningfulness of the project. Whenever necessary, such interim analysis can also call for potential termination or appropriate modification in sample size, study design, and even an early declaration of success. Given the extraordinary size and complexity today, this rational approach helps to analyze and predict the outcomes of a clinical trial that incorporate what is learned during the course of a study or a clinical development program. Such approach can also fill the gap by directing the resources toward relevant and optimized clinical trials between unmet medical needs and interventions being tested currently rather than fulfilling only business and profit goals.
Baig, Arshiya A; Lopez, Fanny Y; DeMeester, Rachel H; Jia, Justin L; Peek, Monica E; Vela, Monica B
Effective shared decision making (SDM) between patients and healthcare providers has been positively associated with health outcomes. However, little is known about the SDM process between Latino patients who identify as lesbian, gay, bisexual, transgender, or queer (LGBTQ), and their healthcare providers. Our review of the literature identified unique aspects of Latino LGBTQ persons' culture, health beliefs, and experiences that may affect their ability to engage in SDM with their healthcare providers. Further research needs to examine Latino LGBTQ patient-provider experiences with SDM and develop tools that can better facilitate SDM in this patient population.
Tessitore, Enrico; Molliqaj, Granit; Schatlo, Bawarjan; Schaller, Karl
In industrialized countries, more than two thirds of the population suffers from low back pain (LBP) in their lifetime. LBP associated with lumbar disc herniation, stenosis, and instability is a well-known and documented entity. On the other hand, the lumbar discogenic pain and facet syndrome are difficult to be clearly identified, and they are not always detectable by imaging. This article describes the causes of these painful syndromes, which are typically without radicular component, explains the modern diagnostic procedures, and provides guidelines for surgical decision making
Tessitore, Enrico, E-mail: firstname.lastname@example.org [Neurosurgical Unit, Geneva University Hospitals, Faculty of Medicine, University of Geneva (Switzerland); Molliqaj, Granit, E-mail: email@example.com [Neurosurgical Unit, Geneva University Hospitals, Faculty of Medicine, University of Geneva (Switzerland); Schatlo, Bawarjan, E-mail: firstname.lastname@example.org [Department of Neurosurgery, Georg-August University, University of Medicine Gottingen, 37075 Gottingen (Germany); Schaller, Karl, E-mail: email@example.com [Neurosurgical Unit, Geneva University Hospitals, Faculty of Medicine, University of Geneva (Switzerland)
In industrialized countries, more than two thirds of the population suffers from low back pain (LBP) in their lifetime. LBP associated with lumbar disc herniation, stenosis, and instability is a well-known and documented entity. On the other hand, the lumbar discogenic pain and facet syndrome are difficult to be clearly identified, and they are not always detectable by imaging. This article describes the causes of these painful syndromes, which are typically without radicular component, explains the modern diagnostic procedures, and provides guidelines for surgical decision making.
Prescott, Jeffrey William
The importance of medical imaging for clinical decision making has been steadily increasing over the last four decades. Recently, there has also been an emphasis on medical imaging for preclinical decision making, i.e., for use in pharamaceutical and medical device development. There is also a drive towards quantification of imaging findings by using quantitative imaging biomarkers, which can improve sensitivity, specificity, accuracy and reproducibility of imaged characteristics used for diagnostic and therapeutic decisions. An important component of the discovery, characterization, validation and application of quantitative imaging biomarkers is the extraction of information and meaning from images through image processing and subsequent analysis. However, many advanced image processing and analysis methods are not applied directly to questions of clinical interest, i.e., for diagnostic and therapeutic decision making, which is a consideration that should be closely linked to the development of such algorithms. This article is meant to address these concerns. First, quantitative imaging biomarkers are introduced by providing definitions and concepts. Then, potential applications of advanced image processing and analysis to areas of quantitative imaging biomarker research are described; specifically, research into osteoarthritis (OA), Alzheimer's disease (AD) and cancer is presented. Then, challenges in quantitative imaging biomarker research are discussed. Finally, a conceptual framework for integrating clinical and preclinical considerations into the development of quantitative imaging biomarkers and their computer-assisted methods of extraction is presented.
This paper reports on ways of improving the reliability of products and systems in this country if we are to survive as a first-rate industrial power. The use of statistical techniques have, since the 1920s, been viewed as one of the methods for testing quality and estimating the level of quality in a universe of output. Statistical quality control is not relevant, generally, to improving systems in an industry like yours, but certainly the use of probability concepts is of significance. In addition, when it is recognized that part of the problem involves making decisions under uncertainty, it becomes clear that techniques such as sequential decision making and Bayesian analysis become major methodological approaches that must be utilized
Paterlini, G; Tagliabue, P
The field of neonatology presents a fascinating context in which hugely important decisions have to be made on the basis of physicians' assessments of the long term consequences of various possible choices. In many cases such assessments cannot be derived from a consensual professional opinion; the situation is characterized by a high level of uncertainty. A sample of neonatologists in different countries received a questionnaire including vignette cases for which no clear consensus exists regarding the (probabilistic) prognosis. They were asked to (I) assess the probability of various outcomes (death, severe impairment) and (II) choose a treatment to be offered to the parents. Information on the physicians' professional and socio-demographic characteristics and their ethical "values" was also collected. The goal of this international survey is to understand the prognosis and to analyze decision making by professionals in the context of life and death in medicine. The availability of an identical technology in different social and institutional contexts should help identifying the convergences and differences under consideration. Seventy percent of those invited responded to the questionnaire (International 60-80%). Italian neonatologists seem to be quite pessimistic about the prognosis of infants at high risk of death or long term disabilities, they show a pro-life attitude, but in a certain proportion are willing to change their minds if requested by parents. Furthermore personal opinions predominate in the decision-making process and the contribution of team meeting and/or ethic consultation seem not significantly modify the decisions.
Florin, Jan; Ehrenberg, Anna; Ehnfors, Margareta
The aim of this study was to compare the degree of concordance between patients and Registered Nurses' perceptions of the patients' preferences for participation in clinical decision-making in nursing care. A further aim was to compare patients' experienced participation with their preferred participatory role. Patient participation in clinical decision-making is valuable and has an effect on quality of care. However, there is limited knowledge about patient preferences for participation and how nurses perceive their patients' preferences. A comparative design was adopted with a convenient sample of 80 nurse-patient dyads. A modified version of the Control Preference Scale was used in conjunction with a questionnaire developed to elicit the experienced participation of the patient. A majority of the Registered Nurses perceived that their patients preferred a higher degree of participation in decision-making than did the patients. Differences in patient preferences were found in relation to age and social status but not to gender. Patients often experienced having a different role than what was initially preferred, e.g. a more passive role concerning needs related to communication, breathing and pain and a more active role related to activity and emotions/roles. Registered Nurses are not always aware of their patients' perspective and tend to overestimate patients' willingness to assume an active role. Registered Nurses do not successfully involve patients in clinical decision-making in nursing care according to their own perceptions and not even to the patients' more moderate preferences of participation. A thorough assessment of the individual's preferences for participation in decision-making seems to be the most appropriate approach to ascertain patient's involvement to the preferred level of participation. The categorization of patients as preferring a passive role, collaborative role or active role is seen as valuable information for Registered Nurses to
Full Text Available Interprofessional relationships may impact the decision making of patients in a clinical setting. The objective of this study was to analyse the decision-making capabilities of patients from nurses’ perspectives of interprofessional relationships using Foucauldian ethics. This qualitative study was based on poststructuralist Foucault references with in-depth interviews of nurses working in internal medicine and specialties in a general hospital. The patients constantly appeared in the definition of teamwork, but also as a passive element used by every professional to communicate with others. Nurses continue modelling a type of patient passivity, or what Foucault called passive subjectivity in relation to oneself, because the patient is guided and directed to take charge of a truth provided by professionals. Nurses must break the rigid design of sections or professional skills, and adopt a model of teamwork that meets the needs of the patient and increases their decision-making power. The quality of care will increase to the extent that professionals establish a relationship of equality with the patient, allowing the patient to make real decisions about their care. An egalitarian model of teamwork is beneficial to the patient, abandoning the idea of a team where the patient and family are constantly excluded from decisions about their care.
Molina-Mula, Jesús; Gallo-Estrada, Julia; Perelló-Campaner, Catalina
Interprofessional relationships may impact the decision making of patients in a clinical setting. The objective of this study was to analyse the decision-making capabilities of patients from nurses' perspectives of interprofessional relationships using Foucauldian ethics. This qualitative study was based on poststructuralist Foucault references with in-depth interviews of nurses working in internal medicine and specialties in a general hospital. The patients constantly appeared in the definition of teamwork, but also as a passive element used by every professional to communicate with others. Nurses continue modelling a type of patient passivity, or what Foucault called passive subjectivity in relation to oneself, because the patient is guided and directed to take charge of a truth provided by professionals. Nurses must break the rigid design of sections or professional skills, and adopt a model of teamwork that meets the needs of the patient and increases their decision-making power. The quality of care will increase to the extent that professionals establish a relationship of equality with the patient, allowing the patient to make real decisions about their care. An egalitarian model of teamwork is beneficial to the patient, abandoning the idea of a team where the patient and family are constantly excluded from decisions about their care.
Full Text Available The aim of the present study was to determine the extent to which employees would like to participate in decision making concerning various organisational issues, especially those concerning: the work itself, working conditions, human resources issues, and corporate policy and planning. The sample consisted of 146 participants, including managers, middle managers, and junior officials from a South African development corporation. A questionnaire to measure employees' desire to participate in decision making was specially constructed for this investigation. It has found that employees with higher academic qualifications were more desirous to participate in decision-making at all levels than employees with lower academic qualifications. This was also true for employees in higher job grades than in lower job grades. Men were more desirous to participate in decision making than women. The implications of the findings are discussed. Opsomming Die doel van die huidige studie was om vas te stel in watter mate werknemers sal wil deelneem aan die besluit- nameproses van organisasies, veral rakende die volgende sake: die werk self, werksomstandighede, menslike hulpbronaangeleenthede en korporatiewe beleid en beplanning. Die steekproef het uit 146 deelnemers, insluitende bestuurders, middelvlakbestuurders en junior amptenare van'n Suid Afrikaanse ontwikkelingskorporasie, bestaan. nVraelys wat die begeerte van werknemers meet om aan die besluitnameproses deel te neem, is spesiaal vir die doel van hierdie ondersoek, ontwerp. Dit is bevind dat werknemers met hoer akademiese kwalifikasies meer begerig is om aan die besluitnameproses op alle vlakke deel te neem as werknemers met laer akademiese kwalifikasies. Dit was ook waar vir werknemers in hoervlakposte vergeleke met werknemers in laervlakposte. Mans was ook meer begerig om aan die besluitnameproses deel te neem as vroue. Die implikasies van die studie word bespreek.
Bian, Jiantao; Morid, Mohammad Amin; Jonnalagadda, Siddhartha; Luo, Gang; Del Fiol, Guilherme
The practice of evidence-based medicine involves integrating the latest best available evidence into patient care decisions. Yet, critical barriers exist for clinicians' retrieval of evidence that is relevant for a particular patient from primary sources such as randomized controlled trials and meta-analyses. To help address those barriers, we investigated machine learning algorithms that find clinical studies with high clinical impact from PubMed®. Our machine learning algorithms use a variety of features including bibliometric features (e.g., citation count), social media attention, journal impact factors, and citation metadata. The algorithms were developed and evaluated with a gold standard composed of 502 high impact clinical studies that are referenced in 11 clinical evidence-based guidelines on the treatment of various diseases. We tested the following hypotheses: (1) our high impact classifier outperforms a state-of-the-art classifier based on citation metadata and citation terms, and PubMed's® relevance sort algorithm; and (2) the performance of our high impact classifier does not decrease significantly after removing proprietary features such as citation count. The mean top 20 precision of our high impact classifier was 34% versus 11% for the state-of-the-art classifier and 4% for PubMed's® relevance sort (p=0.009); and the performance of our high impact classifier did not decrease significantly after removing proprietary features (mean top 20 precision=34% vs. 36%; p=0.085). The high impact classifier, using features such as bibliometrics, social media attention and MEDLINE® metadata, outperformed previous approaches and is a promising alternative to identifying high impact studies for clinical decision support. Copyright © 2017 Elsevier Inc. All rights reserved.
Full Text Available The aim of this study was to describe Dental Foundation year one dentists’ attitudes towards prosthodontic decision making for edentulous patients, and identify whether there are gender differences in these attitudes. All South West Deanery trainees were invited to take part in the study between May and June 2011 and a previously piloted questionnaire was administered to the trainees by their training programme directors. The questionnaire posed questions based upon a clinical scenario of discussing treatment options with patients. Seventy-two questionnaires were used in the analysis (91% overall response rate. Trainees perceived their own values to be less important than the patient’s values (p < 0.001 in decision making, but similar to the patient’s friend’s/relative’s values (p = 0.1. In addition, the trainees perceived the patient’s values to be less important than their friend’s/relatives (p < 0.001. Sixty-six per cent of trainees acknowledged an influence from their own personal values on their presentation of material to patients who are in the process of choosing among different treatment options, and 87% thought their edentulous patients were satisfied with the decision making process when choosing among different treatment options. Fifty-eight per cent of trainees supported a strategy of negotiation between patients and clinicians (shared decision making. There was no strong evidence to suggest gender had an influence on the attitudes towards decision making. The finding of a consensus towards shared decision making in the attitudes of trainees, and no gender differences is encouraging and is supportive of UK dental schools’ ability to foster ethical and professional values among dentists.
Gordon, Bradley D; Bernard, Kyle; Salzman, Josh; Whitebird, Robin R
The objective of the study was to understand the immediate utility of health information exchange (HIE) on emergency department (ED) providers by interviewing them shortly after the information was retrieved. Prior studies of physician perceptions regarding HIE have only been performed outside of the care environment. Trained research assistants interviewed resident physicians, physician assistants and attending physicians using a semi-structured questionnaire within two hours of making a HIE request. The responses were recorded, then transcribed for qualitative analysis. The transcribed interviews were analyzed for emerging qualitative themes. We analyzed 40 interviews obtained from 29 providers. Primary qualitative themes discovered included the following: drivers for requests for outside information; the importance of unexpected information; historical lab values as reference points; providing context when determining whether to admit or discharge a patient; the importance of information in refining disposition; improved confidence of provider; and changes in decisions for diagnostic imaging. ED providers are driven to use HIE when they're missing a known piece of information. This study finds two additional impacts not previously reported. First, providers sometimes find additional unanticipated useful information, supporting a workflow that lowers the threshold to request external information. Second, providers sometimes report utility when no changes to their existing plan are made as their confidence is increased based on external records. Our findings are concordant with previous studies in finding exchanged information is useful to provide context for interpreting lab results, making admission decisions, and prevents repeat diagnostic imaging.
Pelaccia, Thierry; Tardif, Jacques; Triby, Emmanuel; Charlin, Bernard
Making diagnostic and therapeutic decisions is a critical activity among physicians. It relies on the ability of physicians to use cognitive processes and specific knowledge in the context of a clinical reasoning. This ability is a core competency in physicians, especially in the field of emergency medicine where the rate of diagnostic errors is high. Studies that explore medical decision making in an authentic setting are increasing significantly. They are based on the use of qualitative methods that are applied at two separate times: 1) a video recording of the subject's actual activity in an authentic setting and 2) an interview with the subject, supported by the video recording. Traditionally, activity is recorded from an "external perspective"; i.e., a camera is positioned in the room in which the consultation takes place. This approach has many limits, both technical and with respect to the validity of the data collected. The article aims at 1) describing how decision making is currently being studied, especially from a qualitative standpoint, and the reasons why new methods are needed, and 2) reporting how we used an original, innovative approach to study decision making in the field of emergency medicine and findings from these studies to guide further the use of this method. The method consists in recording the subject's activity from his own point of view, by fixing a microcamera on his temple or the branch of his glasses. An interview is then held on the basis of this recording, so that the subject being interviewed can relive the situation, to facilitate the explanation of his reasoning with respect to his decisions and actions. We describe how this method has been used successfully in investigating medical decision making in emergency medicine. We provide details on how to use it optimally, taking into account the constraints associated with the practice of emergency medicine and the benefits in the study of clinical reasoning. The "own
Memon, Arbia; Hamid, Saima; Kumar, Ramesh
Family Planning is the basic right of the human being. It involves decision regarding the number of children and desired space between children by the couple themselves. Quality services involving multiple dimensions build the confidence of the clients and lack of quality is one of the constraints behind incomplete coverage of family planning. Objectives of the current study were to determine the client satisfaction, decision-making process and various influences on clients in adopting family planning methods. This cross-sectional study was conducted at Family Planning Centre of Liaquat University Hospital, Hyderabad in 2016. Quality of the family planning services and satisfaction with the services were assessed through responses obtained from women selected purposively and visiting family planning centre through exit interviews with structured pretested and reliable questionnaire after taking the written consent. Access to Family Planning Centre was not an issue in 92% cases but only 31% respondents were appropriately greeted, 77% faced blank expression and 13% received sufficient privacy. Health problems and socioeconomic conditions were inquired by 41% and18% providers respectively, while motivating force for service use was mother in law in most 35% cases. Health workers were successful in clarifying misinformation (86%) and explaining side effects (71%) but only 21% respondents were satisfied with services. Respondents are influenced by family and health care providers while making decision and type of influence was considered positive by 83% respondents. Training and monitoring system be strengthened at family planning centres to improve quality of services while important influencing relations be focused for family planning education to improve utilization of services.
Full Text Available Journal clubs have been traditionally incorporated into academic training programs to enhance competency in the interpretation of literature. We designed a structured journal club (JC to improve skills in the interpretation of literature; however, we were not aware of how learners (interns, residents, clinical pharmacists, etc. would perceive it. We aimed to assess the perception of learners at different levels of pharmacy training. A cross-sectional design was used. A self-administered online survey was emailed to JC attendees from 2010–2014 at King Abdulaziz Medical City, Jeddah, Saudi Arabia. The survey questions included: introduction sessions, topic selection, JC layout, interaction with the moderator, and decision-making skills by clinical pharmacists. The response rate was 58/89 (65%; 52/54 (96% respondents believed that JC adds to their knowledge in interpreting literature. Topic selection met the core curriculum requirements for credentials exams for 16/36 (44.4%, while 16/22 (73% presenters had good to excellent interaction with the moderator. JC facilitated decision-making for 10/12 (83% of clinical pharmacists. The results suggest that clinical pharmacist-steered JC may serve as an effective tool to empower learners at different levels of pharmacy practice, with evidence-based principles for interpretation of literature and guide informed decision-making.
The challenge of making training decisions with a high degree of confidence as to the results of those decisions face every DOD, Federal, State, and City agency. Training has historically been a very labor and paper intensive system with limited automation support. This paper outlines how one DOD component, the Air Force, is approaching that challenge. The Training Decision System (TDS) will provide the Air Force with an automated decision aid to help plan and estimate the consequences of various mixes of resident training, On-The-Job Training (OJT), and field training within a specialty such as security. The system described provides training from enlistment to separation and responds to hundreds of related security task needs. This system identifies what the tasks are, who should provide the training, what training setting should be used, what proficiency should be achieved, and through computer modeling provides an assessment of training effectiveness options and estimate the impact of implementing those options. With current budgetary constraints and with the possibility of further reductions in the future, the most cost effective training mix must be found to sustain required capabilities
Khammarnia, Mohammad; Setoodezadeh, Fatemeh; Ansari-Moghadam, Alireza; Yusefi, Alireza; Eskandari, Monire; Ranjbar, Arezo Alinejad; Peyvand, Mostafa
Introduction: The study aimed to investigate the relationship between Health literacy (HL) and shared clinical decision-making among cancer patients in Iran. Methods: A cross-sectional questionnaire survey was performed in the south of Iran between January and March of 2017. The study's population was all patients in the southeast of Iran. From here, 500 patients were selected as the study sample by the stratified sampling method. Two standard questionnaires were selected for data-gathering. ...
Decision making in midwifery is a complex process that shapes and underpins clinical practice and determines, to a large extent, the quality of care. Effective decision making and professional accountability are central to clinical governance, and being able.to justify all decisions is a professional and legal requirement. At the same time, there is an emphasis in midwifery on shared decision making, and keeping women at the centre of their care, and research reveals that feelings of choice, control and autonomy are central to a positive birth experience. However the extent to which decisions are really shared and care truly woman-centred is debatable and affected by environment and culture. Using a case study of a decision made in clinical practice around amniotomy, this article explores the role of the intuitive thinking system in midwifery decision making, and highlights the importance of involving women in the decision making process.
Guy, Tatiana Valentine; Wolpert, David H
Prescriptive Bayesian decision making has reached a high level of maturity and is well-supported algorithmically. However, experimental data shows that real decision makers choose such Bayes-optimal decisions surprisingly infrequently, often making decisions that are badly sub-optimal. So prevalent is such imperfect decision-making that it should be accepted as an inherent feature of real decision makers living within interacting societies. To date such societies have been investigated from an economic and gametheoretic perspective, and even to a degree from a physics perspective. However, lit
Gigerenzer, Gerd; Gaissmaier, Wolfgang
As reflected in the amount of controversy, few areas in psychology have undergone such dramatic conceptual changes in the past decade as the emerging science of heuristics. Heuristics are efficient cognitive processes, conscious or unconscious, that ignore part of the information. Because using heuristics saves effort, the classical view has been that heuristic decisions imply greater errors than do "rational" decisions as defined by logic or statistical models. However, for many decisions, the assumptions of rational models are not met, and it is an empirical rather than an a priori issue how well cognitive heuristics function in an uncertain world. To answer both the descriptive question ("Which heuristics do people use in which situations?") and the prescriptive question ("When should people rely on a given heuristic rather than a complex strategy to make better judgments?"), formal models are indispensable. We review research that tests formal models of heuristic inference, including in business organizations, health care, and legal institutions. This research indicates that (a) individuals and organizations often rely on simple heuristics in an adaptive way, and (b) ignoring part of the information can lead to more accurate judgments than weighting and adding all information, for instance for low predictability and small samples. The big future challenge is to develop a systematic theory of the building blocks of heuristics as well as the core capacities and environmental structures these exploit.
Balla, John; Heneghan, Carl; Thompson, Matthew; Balla, Margaret
Examine clinical reasoning and decision making in an out of hours (OOH) primary care setting to gain insights into how general practitioners (GPs) make clinical decisions and manage risk in this environment. Semi-structured interviews using open-ended questions. A 2-month qualitative interview study conducted in Oxfordshire, UK. 21 GPs working in OOH primary care. The most powerful themes to emerge related to dealing with urgent potentially high-risk cases, keeping patients safe and responding to their needs, while trying to keep patients out of hospital and the concept of 'fire fighting'. There were a number of well-defined characteristics that GPs reported making presentations easy or difficult to deal with. Severely ill patients were straightforward, while the older people, with complex multisystem diseases, were often difficult. GPs stopped collecting clinical information and came to clinical decisions when high-risk disease and severe illness requiring hospital attention has been excluded; they had responded directly to the patient's needs and there was a reliable safety net in place. Learning points that GPs identified as important for trainees in the OOH setting included the importance of developing rapport in spite of time pressures, learning to deal with uncertainty and learning about common presentations with a focus on critical cues to exclude severe illness. The findings support suggestions that improvements in primary care OOH could be achieved by including automated and regular timely feedback system for GPs and individual peer and expert clinician support for GPs with regular meetings to discuss recent cases. In addition, trainee support and mentoring to focus on clinical skills, knowledge and risk management issues specific to OOH is currently required. Investigating the stopping rules used for diagnostic closure may provide new insights into the root causes of clinical error in such a high-risk setting.
Chahine, Saad; Cristancho, Sayra; Padgett, Jessica; Lingard, Lorelei
In the competency-based medical education (CBME) approach, clinical competency committees are responsible for making decisions about trainees? competence. However, we currently lack a?theoretical model for group decision-making to inform this emerging assessment phenomenon. This paper proposes an organizing framework to study and guide the decision-making processes of clinical competency committees. This is an explanatory, non-exhaustive review, tailored to identify relevant theoretical and e...
Kristensen, M. S.; Teoh, W. H.; Graumann, O.
OBJECTIVES: To create a state-of-the-art overview of the new and expanding role of ultrasonography in clinical decision-making, intervention and management of the upper and lower airways, that is clinically relevant, up-to-date and practically useful for clinicians. METHODS: This is a narrative...... and help guide timing of removal of chest tubes by quantification of residual pneumothorax size. CONCLUSIONS: Ultrasonography used in conjunction with hands-on management of the upper and lower airways has multiple advantages. There is a rapidly growing body of evidence showing its benefits. TEACHING...
De las Cuevas, Carlos; Peñate, Wenceslao; de Rivera, Luis
To assess the concordance between patients' preferred role in clinical decision-making and the role they usually experience in their psychiatric consultations and to analyze the influence of socio-demographic, clinical and personality characteristics on patients' preferences. 677 consecutive psychiatric outpatients were invited to participate in a cross-sectional survey and 507 accepted. Patients completed Control Preference Scale twice consecutively before consultation, one for their preferences of participation and another for the style they usually experienced until then, and locus of control and self-efficacy scales. Sixty-three percent of psychiatric outpatients preferred a collaborative role in decision-making, 35% preferred a passive role and only a 2% an active one. A low concordance for preferred and experienced participation in medical decision-making was registered, with more than a half of patients wanting a more active role than they actually had. Age and doctors' health locus of control orientation were found to be the best correlates for participation preferences, while age and gender were for experienced. Psychiatric diagnoses registered significant differences in patients' preferences of participation but no concerning experiences. The limited concordance between preferred and experienced roles in psychiatric patients is indicative that clinicians need to raise their sensitivity regarding patient's participation. The assessment of patient's attribution style should be useful for psychiatrist to set objectives and priority in the communication with their patients. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.
Full Text Available Patricia J Manns, Johanna DarrahDepartment of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, CanadaBackground and purpose: Scenarios are used as the basis from which to evaluate the use of the components of evidence-based practice in decision making, yet there are few examples of a standardized process of scenario writing. The aim of this paper is to describe a step-by-step scenario writing method used in the context of the authors’ curriculum research study.Methods: Scenario writing teams included one physical therapy clinician and one academic staff member. There were four steps in the scenario development process: (1 identify prevalent condition and brainstorm interventions; (2 literature search; (3 develop scenario framework; and (4 write scenario.Results: Scenarios focused only on interventions, not diagnostic or prognostic problems. The process led to two types of scenarios – ones that provided an intervention with strong research evidence and others where the intervention had weak evidence to support its use. The end product of the process was a scenario that incorporates aspects of evidence-based decision making and can be used as the basis for evaluation.Conclusion: The use of scenarios has been very helpful to capture therapists’ reasoning processes. The scenario development process was applied in an education context as part of a final evaluation of graduating clinical physical therapy students.Keywords: physical therapists, clinical decision making, evaluation, curriculum
Kaltoft, Mette Kjer; Eiring, Øystein; Nielsen, Jesper Bo
Producing the BEANs needed for person-centred healthcare decision making requires translating the wisdom of the clinical crowd Mette Kjer Kaltoft, University of Southern Denmark Øystein Eiring, Norwegian Knowledge Centre for the Health Services Jesper Bo Nielsen, University of Southern Denmark...... requirement in relation to the BEANs only by assuming professionals are able to make up the shortfalls remaining after the peer-reviewed published products of scientific research have been fully exploited. Since the clinical judgement of individual professionals has never been subjected to scientific...... never get near to meeting the needs of practice. What is required is the translation of the wisdom of the clinical crowd through the processing of the beliefs of expert professionals into BEANs. The process must be appropriately analytically rigorous, but this should not be confounded with scientific...
Artificial intelligence (AI) systems depend heavily upon the ability to make decisions. Decisions require knowledge, yet there is no knowledge-based theory of decision making. To the extent that AI uses a theory of decision-making it adopts components of the traditional statistical view in which choices are made by maximizing some function of the probabilities of decision options. A knowledge-based scheme for reasoning about uncertainty is proposed, which extends the traditional framework but is compatible with it
Serotonin (5-HT) is an important player in decision making. Serotonergic antidepressant, anxiolytic and antipsychotic drugs are extensively used in the treatment of neuropsychiatric disorders characterized by impaired decision making, and exert both beneficial and harmful effects in patients.
Efficace, Fabio; Feuerstein, Michael; Fayers, Peter; Cafaro, Valentina; Eastham, James; Pusic, Andrea; Blazeby, Jane
Context Patient-reported outcomes (PRO) data from randomised controlled trials (RCTs) are increasingly used to inform patient-centred care as well as clinical and health policy decisions. Objective The main objective of this study was to investigate the methodological quality of PRO assessment in RCTs of prostate cancer (PCa) and to estimate the likely impact of these studies on clinical decision making. Evidence acquisition A systematic literature search of studies was undertaken on main electronic databases to retrieve articles published between January 2004 and March 2012. RCTs were evaluated on a predetermined extraction form, including (1) basic trial demographics and clinical and PRO characteristics; (2) level of PRO reporting based on the recently published recommendations by the International Society for Quality of Life Research; and (3) bias, assessed using the Cochrane Risk of Bias tool. Studies were systematically analysed to evaluate their relevance for supporting clinical decision making. Evidence synthesis Sixty-five RCTs enrolling a total of 22 071 patients were evaluated, with 31 (48%) in patients with nonmetastatic disease. When a PRO difference between treatments was found, it related in most cases to symptoms only (n = 29, 58%). Although the extent of missing data was generally documented (72% of RCTs), few reported details on statistical handling of this data (18%) and reasons for dropout (35%). Improvements in key methodological aspects over time were found. Thirteen (20%) RCTs were judged as likely to be robust in informing clinical decision making. Higher-quality PRO studies were generally associated with those RCTs that had higher internal validity. Conclusions Including PRO in RCTs of PCa patients is critical for better evaluating the treatment effectiveness of new therapeutic approaches. Marked improvements in PRO quality reporting over time were found, and it is estimated that at least one-fifth of PRO RCTs have provided sufficient
Bruins, Marjan J; Ruijs, Gijs J H M; Wolfhagen, Maurice J H M; Bloembergen, Peter; Aarts, Jos E C M
Clinicians view the accuracy of test results and the turnaround time as the two most important service aspects of the clinical microbiology laboratory. Because of the time needed for the culturing of infectious agents, final hardcopy culture results will often be available too late to have a significant impact on early antimicrobial therapy decisions, vital in infectious disease management. The clinical microbiologist therefore reports to the clinician clinically relevant preliminary results at any moment during the diagnostic process, mostly by telephone. Telephone reporting is error prone, however. Electronic reporting of culture results instead of reporting on paper may shorten the turnaround time and may ensure correct communication of results. The purpose of this study was to assess the impact of the implementation of electronic reporting of final microbiology results on medical decision making. In a pre- and post-interview study using a semi-structured design we asked medical specialists in our hospital about their use and appreciation of clinical microbiology results reporting before and after the implementation of an electronic reporting system. Electronic reporting was highly appreciated by all interviewed clinicians. Major advantages were reduction of hardcopy handling and the possibility to review results in relation to other patient data. Use and meaning of microbiology reports differ significantly between medical specialties. Most clinicians need preliminary results for therapy decisions quickly. Therefore, after the implementation of electronic reporting, telephone consultation between clinician and microbiologist remained the key means of communication. Overall, electronic reporting increased the workflow efficiency of the medical specialists, but did not have an impact on their decision-making. © 2011 Bruins et al; licensee BioMed Central Ltd.
Full Text Available Abstract Background Clinicians view the accuracy of test results and the turnaround time as the two most important service aspects of the clinical microbiology laboratory. Because of the time needed for the culturing of infectious agents, final hardcopy culture results will often be available too late to have a significant impact on early antimicrobial therapy decisions, vital in infectious disease management. The clinical microbiologist therefore reports to the clinician clinically relevant preliminary results at any moment during the diagnostic process, mostly by telephone. Telephone reporting is error prone, however. Electronic reporting of culture results instead of reporting on paper may shorten the turnaround time and may ensure correct communication of results. The purpose of this study was to assess the impact of the implementation of electronic reporting of final microbiology results on medical decision making. Methods In a pre- and post-interview study using a semi-structured design we asked medical specialists in our hospital about their use and appreciation of clinical microbiology results reporting before and after the implementation of an electronic reporting system. Results Electronic reporting was highly appreciated by all interviewed clinicians. Major advantages were reduction of hardcopy handling and the possibility to review results in relation to other patient data. Use and meaning of microbiology reports differ significantly between medical specialties. Most clinicians need preliminary results for therapy decisions quickly. Therefore, after the implementation of electronic reporting, telephone consultation between clinician and microbiologist remained the key means of communication. Conclusions Overall, electronic reporting increased the workflow efficiency of the medical specialists, but did not have an impact on their decision-making.
Engelhardt, Ellen G.; Révész, Dóra; Tamminga, Hans J.; Punt, Cornelis J. A.; Koopman, Mirjam; Onwuteaka-Philipsen, Bregje D.; Steyerberg, Ewout W.; Jansma, Ilse P.; de Vet, Henrica C. W.; Coupé, Veerle M. H.
Decision-making regarding palliative treatment for patients with metastatic colorectal cancer (mCRC) is complex and comprises numerous decisions. Decision-making should be guided by the premise of maintaining and/or improving patients' quality of life, by patient preference, and by the trade-off
Sanfilippo, Paul G; Hewitt, Alex W; Mackey, David A
To outline and detail the importance of conditional probability in clinical decision making and discuss the various diagnostic measures eye care practitioners should be aware of in order to improve the scope of their clinical practice. We conducted a review of the importance of conditional probability in diagnostic testing for the eye care practitioner. Eye care practitioners use diagnostic tests on a daily basis to assist in clinical decision making and optimizing patient care and management. These tests provide probabilistic information that can enable the clinician to increase (or decrease) their level of certainty about the presence of a particular condition. While an understanding of the characteristics of diagnostic tests are essential to facilitate proper interpretation of test results and disease risk, many practitioners either confuse or misinterpret these measures. In the interests of their patients, practitioners should be aware of the basic concepts associated with diagnostic testing and the simple mathematical rule that underpins them. Importantly, the practitioner needs to recognize that the prevalence of a disease in the population greatly determines the clinical value of a diagnostic test.
Aktaş, Yeşim Yaman; Karabulut, Neziha
Nursing education is a process that includes theoretical and practical learning and requires the acquisition of theoretical knowledge and skill. Nursing students need a good clinical practice environment in order to apply their knowledge and skills due to the fact that the clinical practice settings play an important role in the nursing profession. This study was carried out in an effort to explore nursing students' perception of the clinical learning environment and its association with academic motivation and clinical decision making. A descriptive survey design was used. This study was conducted in Giresun University in Turkey. Participants were second-, third- and fourth-year undergraduate students (n=222) in the Bachelor of Nursing Science Degree in the academic spring term of 2014-2015. The data was collected using the 'Clinical Learning Environment Scale', the 'Academic Motivation, and the 'The Clinical Decision Making in Nursing Scale'. Of the respondents in this study, 45% of the students were second class, 30.6% of the students were third class and 24.3% of the students were fourth class. There was a statistically significant positive correlation found between the clinical learning environment and the nursing students' academic motivation (r=0.182, pdecision making (r=0.082, p>.05). One of the prerequisites for the training of qualified students is to provide nursing students with a qualified clinical environment. It was found that nursing students' academic motivation increased as the quality of their clinical learning environment improved. Copyright © 2015 Elsevier Ltd. All rights reserved.
Hershberg, Julie A; Rose, Dorian K; Tilson, Julie K; Brutsch, Bettina; Correa, Anita; Gallichio, Joann; McLeod, Molly; Moore, Craig; Wu, Sam; Duncan, Pamela W; Behrman, Andrea L
Despite efforts to translate knowledge into clinical practice, barriers often arise in adapting the strict protocols of a randomized, controlled trial (RCT) to the individual patient. The Locomotor Experience Applied Post-Stroke (LEAPS) RCT demonstrated equal effectiveness of 2 intervention protocols for walking recovery poststroke; both protocols were more effective than usual care physical therapy. The purpose of this article was to provide knowledge-translation tools to facilitate implementation of the LEAPS RCT protocols into clinical practice. Participants from 2 of the trial's intervention arms: (1) early Locomotor Training Program (LTP) and (2) Home Exercise Program (HEP) were chosen for case presentation. The two cases illustrate how the protocols are used in synergy with individual patient presentations and clinical expertise. Decision algorithms and guidelines for progression represent the interface between implementation of an RCT standardized intervention protocol and clinical decision-making. In each case, the participant presents with a distinct clinical challenge that the therapist addresses by integrating the participant's unique presentation with the therapist's expertise while maintaining fidelity to the LEAPS protocol. Both participants progressed through an increasingly challenging intervention despite their own unique presentation. Decision algorithms and exercise progression for the LTP and HEP protocols facilitate translation of the RCT protocol to the real world of clinical practice. The two case examples to facilitate translation of the LEAPS RCT into clinical practice by enhancing understanding of the protocols, their progression, and their application to individual participants.Video Abstract available for more insights from the authors (see Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A147).
Alós-Ferrer, Carlos; Hügelschäfer, Sabine; Li, Jiahui
Decision inertia is the tendency to repeat previous choices independently of the outcome, which can give rise to perseveration in suboptimal choices. We investigate this tendency in probability-updating tasks. Study 1 shows that, whenever decision inertia conflicts with normatively optimal behavior (Bayesian updating), error rates are larger and decisions are slower. This is consistent with a dual-process view of decision inertia as an automatic process conflicting with a more rational, controlled one. We find evidence of decision inertia in both required and autonomous decisions, but the effect of inertia is more clear in the latter. Study 2 considers more complex decision situations where further conflict arises due to reinforcement processes. We find the same effects of decision inertia when reinforcement is aligned with Bayesian updating, but if the two latter processes conflict, the effects are limited to autonomous choices. Additionally, both studies show that the tendency to rely on decision inertia is positively associated with preference for consistency.
Reynolds, Teri Ann; Amato, Stas; Kulola, Irene; Chen, Chuan-Jay Jeffrey; Mfinanga, Juma; Sawe, Hendry Robert
Point of care ultrasound (PoCUS) is an efficient, inexpensive, safe, and portable imaging modality that can be particularly useful in resource-limited settings. However, its impact on clinical decision making in such settings has not been well studied. The objective of this study is to describe the utilization and impact of PoCUS on clinical decision making at an urban emergency department in Dar es Salaam, Tanzania. This was a prospective descriptive cross-sectional study of patients receiving PoCUS at Muhimbili National Hospital's Emergency Medical Department (MNH EMD). Data on PoCUS studies during a period of 10 months at MNH EMD was collected on consecutive patients during periods when research assistants were available. Data collected included patient age and sex, indications for ultrasound, findings, interpretations, and provider-reported diagnostic impression and disposition plan before and after PoCUS. Descriptive statistics, including medians and interquartile ranges, and counts and percentages, are reported. Pearson chi squared tests and p-values were used to evaluate categorical data for significant differences. PoCUS data was collected for 986 studies performed on 784 patients. Median patient age was 32 years; 56% of patients were male. Top indications for PoCUS included trauma, respiratory presentations, and abdomino-pelvic pain. The most frequent study types performed were eFAST, cardiac, and obstetric or gynaecologic studies. Overall, clinicians reported that the use of PoCUS changed either diagnostic impression or disposition plan in 29% of all cases. Rates of change in diagnostic impression or disposition plan increased to 45% in patients for whom more than one PoCUS study type was performed. In resource-limited emergency care settings, PoCUS can be utilized for a wide range of indications and has substantial impact on clinical decision making, especially when more than one study type is performed.
rational ones (i.e. Kohlberg’s influential model of decision making ). However, non- rational elements, such as affect, risk perception, risk preference...dread or anxiety) play a strong role in many types of decisions , and that the addition of decision makers’ emotions to models of choice may make ...White, 1994) agree that emotions are an integral part of ethical decision making as well. Emotions arise in the context of interpersonal
Nierenberg, Andrew A; Smoller, Jordan W; Eidelman, Polina; Wu, Yelena P; Tilley, Claire A
Systematic biases in decision-making have been well characterized in medical and nonmedical fields but mostly ignored in clinical psychopharmacology. The purpose of this paper is to sensitize clinicians who prescribe psychiatric drugs to the issues of the psychology of risk, especially as they pertain to the risk of side effects. Specifically, the present analysis focuses on heuristic organization and framing effects that create cognitive biases in medical practice. Our purpose is to increase the awareness of how pharmaceutical companies may influence physicians by framing the risk of medication side effects to favor their products. (c) 2008 S. Karger AG, Basel.
Youngstrom, Eric A; De Los Reyes, Andres
Psychophysiological measures offer a variety of potential advantages, including more direct assessment of certain processes, as well as provision of information that may contrast with other sources. The role of psychophysiological measures in clinical practice will be best defined when researchers (a) switch to research designs and statistical models that better approximate how clinicians administer assessments and make clinical decisions in practice, (b) systematically compare the validity of psychophysiological measures to incumbent methods for assessing similar criteria, (c) test whether psychophysiological measures show either greater validity or clinically meaningful incremental validity, and (d) factor in fiscal costs as well as the utilities that the client attaches to different assessment outcomes. The statistical methods are now readily available, along with the interpretive models for integrating assessment results into client-centered decision making. These, combined with technology reducing the cost of psychophysiological measurement and improving ease of interpretation, poise the field for a rapid transformation of assessment practice, but only if we let go of old habits of research.
Williams, Robert L; Romney, Crystal; Kano, Miria; Wright, Randy; Skipper, Betty; Getrich, Christina M; Sussman, Andrew L; Zyzanski, Stephen J
Research suggests stereotyping by clinicians as one contributor to racial and gender-based health disparities. It is necessary to understand the origins of such biases before interventions can be developed to eliminate them. As a first step toward this understanding, we tested for the presence of bias in senior medical students. The purpose of the study was to determine whether bias based on race, gender, or socioeconomic status influenced clinical decision-making among medical students. We surveyed seniors at 84 medical schools, who were required to choose between two clinically equivalent management options for a set of cardiac patient vignettes. We examined variations in student recommendations based on patient race, gender, and socioeconomic status. The study included senior medical students. We investigated the percentage of students selecting cardiac procedural options for vignette patients, analyzed by patient race, gender, and socioeconomic status. Among 4,603 returned surveys, we found no evidence in the overall sample supporting racial or gender bias in student clinical decision-making. Students were slightly more likely to recommend cardiac procedural options for black (43.9 %) vs. white (42 %, p = .03) patients; there was no difference by patient gender. Patient socioeconomic status was the strongest predictor of student recommendations, with patients described as having the highest socioeconomic status most likely to receive procedural care recommendations (50.3 % vs. 43.2 % for those in the lowest socioeconomic status group, p socioeconomic status, geographic variations, and the influence of interactions between patient race and gender on student recommendations.
Bellamy, Justin L; Mundinger, Gerhard S; Flores, José M; Wimmers, Eric G; Yalanis, Georgia C; Rodriguez, Eduardo D; Sacks, Justin M
Multiple perfusion assessment technologies exist to identify compromised microvascular free flaps. The effectiveness, operability, and cost of each technology vary. The authors investigated surgeon preference and clinical behavior with several perfusion assessment technologies. A questionnaire was sent to members of the American Society for Reconstructive Microsurgery concerning perceptions and frequency of use of several technologies in varied clinical situations. Demographic information was also collected. Adjusted odds ratios were calculated using multinomial logistic regression accounting for clustering of similar practices within institutions/regions. The questionnaire was completed by 157 of 389 participants (40.4 percent response rate). Handheld Doppler was the most commonly preferred free flap-monitoring technology (56.1 percent), followed by implantable Doppler (22.9 percent) and cutaneous tissue oximetry (16.6 percent). Surgeons were significantly more likely to opt for immediate take-back to the operating room when presented with a concerning tissue oximetry readout compared with a concerning handheld Doppler signal (OR, 2.82; p decision making did not significantly differ by demographics, training, or practice setup. Although most surgeons still prefer to use standard handheld Doppler for free flap assessment, respondents were significantly more likely to opt for immediate return to the operating room for a concerning tissue oximetry reading than an abnormal Doppler signal. This suggests that tissue oximetry may have the greatest impact on clinical decision making in the postoperative period.
Beisecker, Analee E.; And Others
Administered Beisecker Locus of Authority in Decision Making: Breast Cancer survey to 67 oncologists, 94 oncology nurses, and 288 patients from women's clinic. All groups believed that physicians should have dominant role in decision making. Nurses felt that patients should have more input than patients or physicians felt they should. Physicians…
Laura E. Slosky
participate were not related to enrollment. Conclusion. Decisions to participate in research by surrogates of children in the PICU appear to relate to child demographics and subtleties in communication; however, no modifiable characteristics were related to increased participation, indicating that the informed consent process may not be compromised in this population.
Horan, William P; Reddy, L Felice; Barch, Deanna M; Buchanan, Robert W; Dunayevich, Eduardo; Gold, James M; Marder, Steven R; Wynn, Jonathan K; Young, Jared W; Green, Michael F
Effort-based decision making has strong conceptual links to the motivational disturbances that define a key subdomain of negative symptoms. However, the extent to which effort-based decision-making performance relates to negative symptoms, and other clinical and functionally important variables has yet to be systematically investigated. In 94 clinically stable outpatients with schizophrenia, we examined the external validity of 5 effort-based paradigms, including the Effort Expenditure for Rewards, Balloon Effort, Grip Strength Effort, Deck Choice Effort, and Perceptual Effort tasks. These tasks covered 3 types of effort: physical, cognitive, and perceptual. Correlations between effort related performance and 6 classes of variables were examined, including: (1) negative symptoms, (2) clinically rated motivation and community role functioning, (3) self-reported motivational traits, (4) neurocognition, (5) other psychiatric symptoms and clinical/demographic characteristics, and (6) subjective valuation of monetary rewards. Effort paradigms showed small to medium relationships to clinical ratings of negative symptoms, motivation, and functioning, with the pattern more consistent for some measures than others. They also showed small to medium relations with neurocognitive functioning, but were generally unrelated to other psychiatric symptoms, self-reported traits, antipsychotic medications, side effects, and subjective valuation of money. There were relatively strong interrelationships among the effort measures. In conjunction with findings from a companion psychometric article, all the paradigms warrant further consideration and development, and 2 show the strongest potential for clinical trial use at this juncture. © The Author 2015. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center. All rights reserved. For permissions, please email: firstname.lastname@example.org.
Herring, Jonathan; Fulford, Kmw; Dunn, Michael; Handa, Ashoki
The UK Supreme Court Montgomery judgment marks a decisive shift in the legal test of duty of care in the context of consent to treatment, from the perspective of the clinician (as represented by Bolam rules) to that of the patient. A majority of commentators on Montgomery have focused on the implications of the judgment for disclosure of risk. In this article, we set risk disclosure in context with three further elements of the judgment: benefits, options, and dialogue. These elements, we argue, taken together with risk disclosure, reflect the origins of the Montgomery ruling in a model of consent based on autonomy of patient choice through shared decision-making with their doctor. This model reflects recent developments in both law and medicine and is widely regarded (by the General Medical Council and others) as representing best practice in contemporary person-centred medicine. So understood, we suggest, the shift marked by Montgomery in the basis of duty of care is a shift in underpinning values: it is a shift from the clinician's interpretation about what would be best for patients to the values of (to what is significant or matters from the perspective of) the particular patient concerned in the decision in question. But the values of the particular patient do not thereby become paramount. The Montgomery test of duty of care requires the values of the particular patient to be balanced alongside the values of a reasonable person in the patient's position. We illustrate some of the practical challenges arising from the balance of considerations required by Montgomery with examples from surgical care. These examples show the extent to which Montgomery, in mirroring the realities of clinical decision-making, provides elbowroom for best practice in person-centred clinical care. © The Author 2017. Published by Oxford University Press; all rights reserved. For Permissions, please email: email@example.com.
Duran-Nelson, Alisa; Gladding, Sophia; Beattie, Jim; Nixon, L James
To determine which resources residents use at the point-of-care (POC) for decision making, the drivers for selection of these resources, and how residents use Google/Google Scholar to answer clinical questions at the POC. In January 2012, 299 residents from three internal medicine residencies were sent an electronic survey regarding resources used for POC decision making. Resource use frequency and factors influencing choice were determined using descriptive statistics. Binary logistic regression analysis was performed to determine relationships between the independent variables. A total of 167 residents (56%) responded; similar numbers responded at each level of training. Residents most frequently reported using UpToDate and Google at the POC at least daily (85% and 63%, respectively), with speed and trust in the quality of information being the primary drivers of selection. Google, used by 68% of residents, was used primarily to locate Web sites and general information about diseases, whereas Google Scholar, used by 30% of residents, tended to be used for treatment and management decisions or locating a journal article. The findings suggest that internal medicine residents use UpToDate most frequently, followed by consultation with faculty and the search engines Google and Google Scholar; speed, trust, and portability are the biggest drivers for resource selection; and time and information overload appear to be the biggest barriers to resources such as Ovid MEDLINE. Residents frequently used Google and may benefit from further training in information management skills.
Ranzani, Otavio T; Prina, Elena; Menéndez, Rosario; Ceccato, Adrian; Cilloniz, Catia; Méndez, Raul; Gabarrus, Albert; Barbeta, Enric; Bassi, Gianluigi Li; Ferrer, Miquel; Torres, Antoni
The Sepsis-3 Task Force updated the clinical criteria for sepsis, excluding the need for systemic inflammatory response syndrome (SIRS) criteria. The clinical implications of the proposed flowchart including the quick Sequential (Sepsis-related) Organ Failure Assessment (qSOFA) and SOFA scores are unknown. To perform a clinical decision-making analysis of Sepsis-3 in patients with community-acquired pneumonia. This was a cohort study including adult patients with community-acquired pneumonia from two Spanish university hospitals. SIRS, qSOFA, the Confusion, Respiratory Rate and Blood Pressure (CRB) score, modified SOFA (mSOFA), the Confusion, Urea, Respiratory Rate, Blood Pressure and Age (CURB-65) score, and Pneumonia Severity Index (PSI) were calculated with data from the emergency department. We used decision-curve analysis to evaluate the clinical usefulness of each score and the primary outcome was in-hospital mortality. Of 6,874 patients, 442 (6.4%) died in-hospital. SIRS presented the worst discrimination, followed by qSOFA, CRB, mSOFA, CURB-65, and PSI. Overall, overestimation of in-hospital mortality and miscalibration was more evident for qSOFA and mSOFA. SIRS had lower net benefit than qSOFA and CRB, significantly increasing the risk of over-treatment and being comparable with the "treat-all" strategy. PSI had higher net benefit than mSOFA and CURB-65 for mortality, whereas mSOFA seemed more applicable when considering mortality/intensive care unit admission. Sepsis-3 flowchart resulted in better identification of patients at high risk of mortality. qSOFA and CRB outperformed SIRS and presented better clinical usefulness as prompt tools for patients with community-acquired pneumonia in the emergency department. Among the tools for a comprehensive patient assessment, PSI had the best decision-aid tool profile.
Waldrop, Deborah P; Meeker, Mary Ann
This study explored the process of decision making about hospice enrollment and identified factors that influence the timing of that decision. This study employed an exploratory, descriptive, cross-sectional design and was conducted using qualitative methods. In-depth in-person semistructured interviews were conducted with 36 hospice patients and 55 caregivers after 2 weeks of hospice care. The study was guided by Janis and Mann's conflict theory model (CTM) of decision making. Qualitative data analysis involved a directed content analysis using concepts from the CTM. A model of hospice enrollment decision making is presented. Concepts from the CTM (appraisal, surveying and weighing the alternatives, deliberations, adherence) were used as an organizing framework to illustrate the dynamics. Distinct differences were found by diagnosis (cancer vs. other chronic illness, e.g., heart and lung diseases) during the pre-encounter phase or before the hospice referral but no differences emerged during the post-encounter phase. Differences in decision making by diagnosis suggest the need for research about effective means for tailored communication in end-of-life decision making by type of illness. Recognition that decision making about hospice admission varies is important for clinicians who aim to provide person-centered and family-focused care.
AL-Dossary, Reem; Kitsantas, Panagiota; Maddox, P J
Health care institutions have adapted residency programs to help new graduate nurses to become fully competent and transition from a student nurse to an independent practicing nurse and a bedside leader. The study's aim is to review the literature on the impact of residency programs on new graduate nurses' clinical decision-making and leadership skills. An electronic search was conducted between 1980 and 2013 using databases of the scientific literature in Medline, PubMed, Cochrane EPOC, Cumulative Index to Nursing & Allied Health Literature database guide (CINAHL), and PsychInfo using a range of keywords. Information gathered was evaluated for relevance. Thirteen studies that met the inclusion criteria were used in this systematic review. In several studies considered in this review, residency programs were developed to improve new graduates skills and promote their transition into the nursing workforce. In fact, the transition programs reduced turnover in that first year of practice and promoted professional growth of the new graduate such as hand-on nursing skills, clinical decision-making and leadership skills, satisfaction, and retention. There is a need for effective residency programs that are designed to prepare new graduate nurses in providing safe, competent and effective patient care. © 2013.
Johnsen, Hege Mari; Fossum, Mariann; Vivekananda-Schmidt, Pirashanthie; Fruhling, Ann; Slettebø, Åshild
Serious games (SGs) are a type of simulation technology that may provide nursing students with the opportunity to practice their clinical reasoning and decision-making skills in a safe and authentic environment. Despite the growing number of SGs developed for healthcare professionals, few SGs are video based or address the domain of home health care. This paper aims to describe the design, development, and usability evaluation of a video based SG for teaching clinical reasoning and decision-making skills to nursing students who care for patients with chronic obstructive pulmonary disease (COPD) in home healthcare settings. A prototype SG was developed. A unified framework of usability called TURF (Task, User, Representation, and Function) and SG theory were employed to ensure a user-centered design. The educational content was based on the clinical decision-making model, Bloom's taxonomy, and a Bachelor of Nursing curriculum. A purposeful sample of six participants evaluated the SG prototype in a usability laboratory. Cognitive walkthrough evaluations, a questionnaire, and individual interviews were used for the usability evaluation. The data were analyzed using qualitative deductive content analysis based on the TURF framework elements and related usability heuristics. The SG was perceived as being realistic, clinically relevant, and at an adequate level of complexity for the intended users. Usability issues regarding functionality and the user-computer interface design were identified. However, the SG was perceived as being easy to learn, and participants suggested that the SG could serve as a supplement to traditional training in laboratory and clinical settings. Using video based scenarios with an authentic COPD patient and a home healthcare registered nurse as actors contributed to increased realism. Using different theoretical approaches in the SG design was considered an advantage of the design process. The SG was perceived as being useful, usable, and
Decisions are made according to a complex cognitive and emotional evaluation of the situation. The aim of the paper is to examine the effect of mood on risky investment decision making by using a mood induction procedure. The paper investigates how happy and sad mood affects risky investment decision making and whether there is a difference between the perception of fix investments and monetary investments. The analysis has been conducted focusing on individual investment decisions. Data for ...
Feng, Jun; Gong, Jingjing; Huang, Yonghua; Wei, Yazhou; Zhang, Weiwei; Zhang, Yan
Numerous studies have demonstrated the robustness of the framing effect in a variety of contexts, especially in medical decision making. Unfortunately, research is still inconsistent as to how so many variables impact framing effects in medical decision making. Additionally, much attention should be paid to the framing effect not only in hypothetical scenarios but also in clinical experience.
Gong, Jingjing; Zhang, Yan; Feng, Jun; Huang, Yonghua; Wei, Yazhou; Zhang, Weiwei
Numerous studies have demonstrated the robustness of the framing effect in a variety of contexts, especially in medical decision making. Unfortunately, research is still inconsistent as to how so many variables impact framing effects in medical decision making. Additionally, much attention should be paid to the framing effect not only in hypothetical scenarios but also in clinical experience.
Gong, Jingjing; Zhang, Yan; Feng, Jun; Huang, Yonghua; Wei, Yazhou; Zhang, Weiwei
Numerous studies have demonstrated the robustness of the framing effect in a variety of contexts, especially in medical decision making. Unfortunately, research is still inconsistent as to how so many variables impact framing effects in medical decision making. Additionally, much attention should be paid to the framing effect not only in hypothetical scenarios but also in clinical experience. PMID:27034630
Connolly, T.; Zeelenberg, M.
Decision research has only recently started to take seriously the role of emotions in choices and decisions. Regret is the emotion that has received the most attention. In this article, we sample a number of the initial regret studies from psychology and economics, and trace some of the complexities
We sometimes make decisions relying not necessarily on deliberative thoughts but on intuitive and emotional processes in uncertain situations. The somatic marker hypothesis proposed by Damasio argued that interoception, which means bodily responses such as sympathetic activity, can be represented in the insula and anterior cingulate cortex and can play critical roles in decision-making. Though this hypothesis has been criticized in its theoretical and empirical aspects, recent studies are expanding the hypothesis to elucidate multiple bodily responses including autonomic, endocrine, and immune activities that affect decision-making. In addition, cumulative findings suggest that the anterior insula where the inner model of interoception is represented can act as an interface between the brain and body in decision-making. This article aims to survey recent findings on the brain-body interplays underlying decision-making, and to propose hypotheses on the significance of the body in decision-making.
Maneval, Rhonda; Fowler, Kimberly A; Kays, John A; Boyd, Tiffany M; Shuey, Jennifer; Harne-Britner, Sarah; Mastrine, Cynthia
This study was conducted to determine whether the addition of high-fidelity patient simulation to new nurse orientation enhanced critical thinking and clinical decision-making skills. A pretest-posttest design was used to assess critical thinking and clinical decision-making skills in two groups of graduate nurses. Compared with the control group, the high-fidelity patient simulation group did not show significant improvement in mean critical thinking or clinical decision-making scores. When mean scores were analyzed, both groups showed an increase in critical thinking scores from pretest to posttest, with the high-fidelity patient simulation group showing greater gains in overall scores. However, neither group showed a statistically significant increase in mean test scores. The effect of high-fidelity patient simulation on critical thinking and clinical decision-making skills remains unclear. Copyright 2012, SLACK Incorporated.
desired effect (Eagly, & Chaiken, 1993). Arguably, artificial intelligence is representative of the best of approaches in rational decision - making ...2001), The quantum of social action and the function of emotion in decision - making , Emotional and Intelligent II: The Tangled Knot of Social...Collaborative decision making in METOC W.F. Lawless Paine College, Departments of Mathematics and Psychology Augusta, GA 30901-3182 ph: 706
Darby, R Ryan; Dickerson, Bradford C
After participating in this activity, learners should be better able to:• Assess the neuropsychological literature on decision making and the medical and legal assessment of capacity in patients with dementia• Identify the limitations of integrating findings from decision-making research into capacity assessments for patients with dementia ABSTRACT: Medical and legal professionals face the challenge of assessing capacity and competency to make medical, legal, and financial decisions in dementia patients with impaired decision making. While such assessments have classically focused on the capacity for complex reasoning and executive functions, research in decision making has revealed that motivational and metacognitive processes are also important. We first briefly review the neuropsychological literature on decision making and on the medical and legal assessment of capacity. Next, we discuss the limitations of integrating findings from decision-making research into capacity assessments, including the group-to-individual inference problem, the unclear role of neuroimaging in capacity assessments, and the lack of capacity measures that integrate important facets of decision making. Finally, we present several case examples where we attempt to demonstrate the potential benefits and important limitations of using decision-making research to aid in capacity determinations.
Sharma, Tarang; Choudhury, Moni; Kaur, Bindweep
from the literature and a combined best practice checklist has been proposed. CONCLUSIONS: As decisions often need to be made in areas where there is a lack of published scientific evidence, CE is employed. Therefore to ensure its appropriateness the development of a validated CE data quality check......-list to assist decision makers is essential and further research in this area is a priority....
In many application areas, it is necessary to make effective decisions under constraints. Several area-specific techniques are known for such decision problems; however, because these techniques are area-specific, it is not easy to apply each technique to other applications areas. Cross-fertilization between different application areas is one of the main objectives of the annual International Workshops on Constraint Programming and Decision Making. Those workshops, held in the US (El Paso, Texas), in Europe (Lyon, France), and in Asia (Novosibirsk, Russia), from 2008 to 2012, have attracted researchers and practitioners from all over the world. This volume presents extended versions of selected papers from those workshops. These papers deal with all stages of decision making under constraints: (1) formulating the problem of multi-criteria decision making in precise terms, (2) determining when the corresponding decision problem is algorithmically solvable; (3) finding the corresponding algorithms, and making...
Salloch, Sabine; Otte, Ina; Reinacher-Schick, Anke; Vollmann, Jochen
Physicians' clinical expertise forms an exclusive body of competences, which helps them to find the appropriate diagnostics and treatment for each individual patient. Empirical evidence, however, suggests that there is an inverse relationship between the number of years in practice and the quality of care provided by a physician. Knowledge and adherence to professional standards (such as clinical guidelines) are often used as indicators in previous research. Semistructured interviews and the Q method were used for an explorative study on oncologists' views on the interplay between their own clinical expertise, intuition, and the external evidence incorporated in clinical guidelines. The interviews were audio recorded, transcribed ad verbatim, and analysed using qualitative content analysis. Data analysis shows the complex character of clinical expertise with respect to experience, professional development, and intuition. An irreplaceable role is attributed to personal and bodily experience during the providing of care for a patient. Professional experience becomes important, particularly in those situations that lie out of the focus of "guideline medicine." Intuition is regarded as having a strong emotional component and helps for deciding which therapeutic option the patient can deal with. Using measurable knowledge and adherence to standards as indicators does not account for the complexity of clinical expertise. Other factors, such as the importance of bodily experience and physicians' intuitive knowledge, must be considered, also with respect to the occurrence of treatment biases. © 2017 John Wiley & Sons, Ltd.
Ventegodt, Søren; Kandel, Isack; Merrick, Joav
Scientific holistic medicine is built on holistic medical theory, on therapeutic and ethical principles. The rationale is that the therapist can take the patient into a state of salutogenesis, or existential healing, using his skills and knowledge. But how ever much we want to make therapy a science it remains partly an art, and the more developed the therapist becomes, the more of his/her decisions will be based on intuition, feeling and even inspiration that is more based on love and human concern and other spiritual motivations than on mental reason and rationality in a simple sense of the word. The provocative and paradoxal medieval western concept of the "truth telling clown", or the eastern concepts of "crazy wisdom" and "holy madness" seems highly relevant here. The problem is how we can ethically justify this kind of highly "irrational" therapeutic behavior in the rational setting of a medical institution. We argue here that holistic therapy has a very high success rate and is doing no harm to the patient, and encourage therapists, psychiatrists, psychologist and other academically trained "helpers" to constantly measure their own success-rate. This paper discusses many of the important factors that influence clinical holistic decision-making. Sexuality could, as many psychoanalysts from Freud to Reich and Searles have believed, be the most healing power that exists and also the most difficult for the mind to comprehend, and thus the most "crazy-wise" tool of therapy.
Christopher A. Dieckmann, PE, CSEP-Acq
The Idaho National Laboratory (INL) is funded through the Department of Energy (DOE) Office of Nuclear Energy and other customers who have direct contracts with the Laboratory. The people, equipment, facilities and other infrastructure at the laboratory require continual investment to maintain and improve the laboratory’s capabilities. With ever tightening federal and customer budgets, the ability to direct investments into the people, equipment, facilities and other infrastructure which are most closely aligned with the laboratory’s mission and customers’ goals grows increasingly more important. The ability to justify those investment decisions based on objective criteria that can withstand political, managerial and technical criticism also becomes increasingly more important. The Systems Engineering tools of decision analysis, risk management and roadmapping, when properly applied to such problems, can provide defensible decisions.
Arthur, R.; Sibani, P.
We discuss fitness landscapes and how they can be modified to account for co-evolution. We are interested in using the landscape as a way to model rational decision making in a toy economic system. We develop a model very similar to the Tangled Nature Model of Christensen et al. that we call the Tangled Decision Model. This is a natural setting for our discussion of co-evolutionary fitness landscapes. We use a Monte Carlo step to simulate decision making and investigate two different decision making procedures.
Arthur, Rudy; Sibani, Paolo
We discuss fitness landscapes and how they can be modified to account for co-evolution. We are interested in using the landscape as a way to model rational decision making in a toy economic system. We develop a model very similar to the Tangled Nature Model of Christensen et. al. that we call...... the Tangled Decision Model. This is a natural setting for our discussion of co-evolutionary fitness landscapes. We use a Monte Carlo step to simulate decision making and investigate two different decision making procedures....
Business educators should give students specific training in a methodology which will enable them to make logical, systematic, and rational decisions. Kepner-Tregoe Analysis (KTA), a decision making model, is described and illustrated with an example of a student buying his first car. (SC)
A M Kustubayeva
Full Text Available The results of the experimental research of the connection between the efficiency of decision making and emotional intelligence are presented in the article. The empirical data indicate that the ability to regulate emotion is an important indicator of the efficiency of decision making in the conditions of psychological experiment.
Masuda, Elna M; Lee, Raymond W; Okazaki, Ian J; Benyamini, Pouya; Kistner, Robert L
Management of venous thromboembolism (VTE) includes evaluation for hypercoagulable state, especially if the VTE occurs in young patients, is recurrent, or is associated with a positive family history. These laboratory tests are costly, and surprisingly, there is little evidence showing that testing leads to improved clinical outcomes. Evidence based on observational prospective studies suggests that optimal duration of anticoagulation should be based on clinical risks resulting in VTE, such as transient, permanent, and idiopathic or unprovoked risks, and less on abnormal thrombophilia values. Thrombophilia screening is important in a subgroup of clinical scenarios, such as when there is clinical suspicion of antiphospholipid antibody syndrome, heparin resistance, or warfarin necrosis; with thrombosis occurring in unusual sites (such as mesenteric or cerebral deep venous thrombosis); and for pregnant women or those seeking pregnancy or considering estrogen-based agents. Thrombophilia screening is not likely to be helpful in most cases of first-time unprovoked VTE in the setting of transient risks, active malignant disease, deep venous thrombosis of upper extremity veins or from central lines, two or more VTEs, or arterial thrombosis with pre-existing atherosclerotic risk factors. The desire by both patient and physician for a scientific explanation of the clotting event may alone lead to testing, and if so, it should be with the understanding that an abnormal test result will likely not change management, and normal results do not accurately exclude a thrombophilic defect because there are likely factors yet to be discovered. Such false assumptions may lead to shorter durations of treatment than are optimal. Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.
Brink, James A.
Although many efforts have been made to reduce the radiation dose associated with individual medical imaging examinations to ''as low as reasonably achievable,'' efforts to ensure such examinations are performed only when medically indicated and appropriate are equally if not more important. Variations in the use of ionizing radiation for medical imaging are concerning, regardless of whether they occur on a local, regional or national basis. Such variations among practices can be reduced with the use of decision support tools at the time of order entry. These tools help reduce radiation exposure among practices through the appropriate use of medical imaging. Similarly, adoption of best practices among imaging facilities can be promoted through tracking the radiation exposure among imaging patients. Practices can benchmark their aggregate radiation exposures for medical imaging through the use of dose index registries. However several variables must be considered when contemplating individual patient dose tracking. The specific dose measures and the variation among them introduced by variations in body habitus must be understood. Moreover the uncertainties in risk estimation from dose metrics related to age, gender and life expectancy must also be taken into account. (orig.)
Duggan, Conor; Mason, Lauren; Banerjee, Penny; Milton, John
Assessing those with personality disorder for treatment in secure settings is known to be unsatisfactory. To examine the utility of a standardised assessment of offenders with personality disorder referred for treatment in secure care in a naturalistic study. A consecutive series of 89 men were assessed with a battery of four recommended instruments measuring personality and risk. Decisions on whether or not to admit were based on a multidisciplinary discussion informed by these assessments. Of the 89 comprehensively assessed referrals, 60 (67%) were offered admission. High scores on the Psychopathy Checklist-Revised (especially on Factor 1) was the only measure that was associated with rejection. Of 44 patients discharged, 29 (66%) failed to complete treatment; none of the pre-admission assessments distinguished ;completers' from ;non-completers'. Although skills were acquired on the unit, follow-up of 24 men in the community showed that this had only a marginal effect on re-offending rate (58%). Current recommended assessment methods appear unsatisfactory in identifying those who either (a) complete treatment or (b) benefit from treatment. Our results throw doubt on their value.
Brink, James A. [Massachusetts General Hospital, Harvard Medical School, Department of Radiology, Boston, MA (United States)
Although many efforts have been made to reduce the radiation dose associated with individual medical imaging examinations to ''as low as reasonably achievable,'' efforts to ensure such examinations are performed only when medically indicated and appropriate are equally if not more important. Variations in the use of ionizing radiation for medical imaging are concerning, regardless of whether they occur on a local, regional or national basis. Such variations among practices can be reduced with the use of decision support tools at the time of order entry. These tools help reduce radiation exposure among practices through the appropriate use of medical imaging. Similarly, adoption of best practices among imaging facilities can be promoted through tracking the radiation exposure among imaging patients. Practices can benchmark their aggregate radiation exposures for medical imaging through the use of dose index registries. However several variables must be considered when contemplating individual patient dose tracking. The specific dose measures and the variation among them introduced by variations in body habitus must be understood. Moreover the uncertainties in risk estimation from dose metrics related to age, gender and life expectancy must also be taken into account. (orig.)
May, Stephen A
Confusion about the nature of human reasoning and its appropriate application to patients has hampered veterinary students' development of these skills. Expertise is associated with greater ability to deploy pattern recognition (type 1 reasoning), which is aided by progressive development of data-driven, forward reasoning (in contrast to scientific, backward reasoning), analytical approaches that lead to schema acquisition. The associative nature of type 1 reasoning makes it prone to bias, particularly in the face of "cognitive miserliness," when clues that indicate the need for triangulation with an analytical approach are ignored. However, combined reasoning approaches, from the earliest stages, are more successful than one approach alone, so it is important that those involved in curricular design and delivery promote student understanding of reasoning generally, and the situations in which reasoning goes awry, and develop students' ability to reason safely and accurately whether presented with a familiar case or with a case that they have never seen before.
Orasanu, Judith; Shafto, Michael G. (Technical Monitor)
The Importance of decision-making to safety in complex, dynamic environments like mission control centers, aviation, and offshore installations has been well established. NASA-ARC has a program of research dedicated to fostering safe and effective decision-making in the manned spaceflight environment. Because access to spaceflight is limited, environments with similar characteristics, including aviation and nuclear power plants, serve as analogs from which space-relevant data can be gathered and theories developed. Analyses of aviation accidents cite crew judgement and decision making as causes or contributing factors in over half of all accidents. Yet laboratory research on decision making has not proven especially helpful In improving the quality of decisions in these kinds of environments. One reason is that the traditional, analytic decision models are inappropriate to multi-dimensional, high-risk environments, and do not accurately describe what expert human decision makers do when they make decisions that have consequences. A new model of dynamic, naturalistic decision making is offered that may prove useful for improving decision making in complex, isolated, confined and high-risk environments. Based on analyses of crew performance in full-mission simulators and accident reports, features that define effective decision strategies in abnormal or emergency situations have been identified. These include accurate situation assessment (including time and risk assessment), appreciation of the complexity of the problem, sensitivity to constraints on the decision, timeliness of the response, and use of adequate information. More effective crews also manage their workload to provide themselves with time and resources to make good decisions. In brief, good decisions are appropriate to the demands of the situation. Effective crew decision making and overall performance are mediated by crew communication. Communication contributes to performance because it assures that
Dumbrava, Ecaterina Ileana; Meric-Bernstam, Funda
Next-generation sequencing (NGS), also known as massively parallel sequencing, is rapidly being incorporated into oncology practice. Interpretation of genomic reports and selecting treatments based on the tumor's genomic analysis becomes more and more complicated for the treating oncologist because of the use of larger panels covering dozens to hundreds of genes and the amount of rapidly emerging clinical/translational data. To help guide personalized treatments in oncology, The Sheikh Khalifa Bin Zayed Al Nahyan Institute for Personalized Cancer Therapy (IPCT) at MD Anderson Cancer Center has developed a knowledge base, available at https://personalizedcancertherapy.org or https://pct.mdanderson.org (PCT). This knowledge base provides information on the function of common genomic alterations and their therapeutic implications. Here, we describe how such genomic information can be used by health-care providers to identify genomically matched therapies. PMID:29212833
Bliddal, Henning; Christensen, Robin
BACKGROUND: Osteoarthritis (OA) is a major cause of disability, which will increase further with longer lifetime and higher average weight of the population. OBJECTIVE: To review a hierarchy of interventions for OA in clinical practice, and compare it with the Strength of Recommendation (SOR......) proposed by the Osteoarthritis Research Society International (OARSI). METHODS: Search for relevant randomized controlled trials in databases, as well as published systematic reviews and meta-analyses. RESULTS/CONCLUSIONS: Preventive measures are few and uncertain; however, basic therapy includes reduction...... in weight in the obese and exercises to keep in shape; this is in accordance with the OARSI guidelines (OARSI, 100% consensus) emphasizing the need for obese individuals with knee OA to lose weight (OARSI, SOR = 96%). There are indications of an effect of some nutraceuticals, though further studies...
Moore Ernest E
Full Text Available Abstract Metabolic changes after major trauma have a complex underlying pathophysiology. The early posttraumatic stress response is associated with a state of hyperinflammation, with increased oxygen consumption and energy expenditure. This hypercatabolic state must be recognized early and mandates an early nutritional management strategy. A proactive concept of early enteral "immunonutrition" in severely injured patients, is aimed at counterbalancing the negative aspects of hyperinflammation and hypercatabolism in order to reduce the risk of late complications, including infections and posttraumatic organ failure. Recently, the concept of "metabolic staging" has been advocated, which takes into account the distinct inflammatory phases and metabolic phenotypes after major trauma, including the "ischemia/reperfusion phenotype", the "leukocytic phenotype", and the "angiogenic phenotype". The potential clinical impact of metabolic staging, and of an appropriately adapted "metabolic control" and nutritional support, remains to be determined.
Full Text Available Advances made in genetic testing and tools applied to pharmacogenetics are increasingly being used to inform clinicians in fields such as oncology, hematology, diabetes (endocrinology, cardiology and expanding into psychiatry by examining the influences of genetics on drug efficacy and metabolism. We present a clinical case example of an adolescent male with anxiety, attention deficit hyperactivity disorder (ADHD and autism spectrum disorder who did not tolerate numerous medications and dosages over several years in attempts to manage his symptoms. Pharmacogenetics testing was performed and DNA results on this individual elucidated the potential pitfalls in medication use because of specific pharmacodynamic and pharmacokinetic differences specifically involving polymorphisms of genes in the cytochrome p450 enzyme system. Future studies and reports are needed to further illustrate and determine the type of individualized medicine approach required to treat individuals based on their specific gene patterns. Growing evidence supports this biological approach for standard of care in psychiatry.
Full Text Available Decision-making is defined as a selection of a certain actionamong several alternatives. It is the essence of planning, asin the managerial sense there is no plan until a decision of engagementof resources, reputation and direction of activities ismade. Decision-making is, in fact, only a step in planning, evenwhen it is performed quickly and without special consideration.It is what we all experience every day. It is one of the most fascinatingbiological activities and the subject of frightening implicationsfor the whole human race. Since various techniques improvethe system and the quality of managerial decision-making,they are classified into three assumptions: risk analysis, decision-making trees, and the theory of revealed preference. Allof these are based on the interaction of a certain number of importantvariables out of which many contain the elements ofuncertainty, but maybe also high level of probability.
Rough Set TheoryBasic concepts and properties of rough sets Rough Membership Rough Intervals Rough FunctionApplications of Rough SetsMultiple Objective Rough Decision Making Reverse Logistics Problem with Rough Interval Parameters MODM based Rough Approximation for Feasible RegionEVRMCCRMDCRM Reverse Logistics Network Design Problem of Suji Renewable Resource MarketBilevel Multiple Objective Rough Decision Making Hierarchical Supply Chain Planning Problem with Rough Interval Parameters Bilevel Decision Making ModelBL-EVRM BL-CCRMBL-DCRMApplication to Supply Chain Planning of Mianyang Co., LtdStochastic Multiple Objective Rough Decision Multi-Objective Resource-Constrained Project Scheduling UnderRough Random EnvironmentRandom Variable Stochastic EVRM Stochastic CCRM Stochastic DCRM Multi-Objective rc-PSP/mM/Ro-Ra for Longtan Hydropower StationFuzzy Multiple Objective Rough Decision Making Allocation Problem under Fuzzy Environment Fuzzy Variable Fu-EVRM Fu-CCRM Fu-DCRM Earth-Rock Work Allocation Problem.
Duong, Michelle; Bertin, Kendra; Henry, Renee; Singh, Deepti; Timmins, Nolla; Brooks, Dina; Mathur, Sunita
ABSTRACT Purpose: To develop and evaluate a preliminary clinical decision-making tool (CDMT) to assist physiotherapists in titrating oxygen for acutely ill adults in Ontario. Methods: A panel of 14 experienced cardiorespiratory physiotherapists was recruited. Factors relating to oxygen titration were identified using a modified Delphi technique. Four rounds of questionnaires were conducted, during which the goals were to (1) generate factors, (2) reduce factors and debate contentious factors, (3) finalize factors and develop the preliminary CDMT, and (4) evaluate the usability of the tool in a clinical context. Results: The panel reached consensus on a total of 89 factors, which were compiled to create the preliminary CDMT. The global tool reached consensus for sensibility, receiving a mean score of 6/7 on a 7-point Likert-type scale (1=unacceptable; 7=excellent). Five of the nine individual components of evaluation of the tool achieved scores ≥6.0; the remaining four had mean scores between 5.4 and 5.9. Conclusion: This study produced a preliminary CDMT for oxygen titration, which the panel agreed was highly comprehensible and globally sensible. Further research is necessary to evaluate the sensibility and applicability of the tool in a clinical setting. PMID:25125782
Whenever the user of a consultation system needs to know a large amount of information items that are possibly inter-related, a system that is able to cooperate with the user can simplify the interaction and increase its speed. In fact, these systems can recognize the goals of the user, individuate the information related to his goals, and finally focus their attention on this information . This paper describes research work on the design and creation of a medical folder management system capable of establishing cooperative dialogue with users who have access to the information contained therein. Particular attention has thus been paid to the problems of man-computer dialogue and user models. The research work has addressed the problem of integrating into the system knowledge about the medical domain and users (physicians are only used for the time being), which are both necessary to activate a cooperative dialogue. After analysing the literature on the problems of user models, this paper presents and formalizes a study performed at the IVth Surgical Clinic of the Rome University Umberto I General Hospital to identify and represent how, when, and with what goals the physician consults the medical folder, as well as the dialogue procedures he normally adopts. The paper also illustrates important characteristics of the CADMIO prototype, which has been developed since the study was made. CADMIO stores information about users for use in recognizing and interpreting their behaviour, providing help, and in acquiring and returning further information. Whilst always bearing in mind the physician's pre-established goals, it structures information to facilitate his consultation activity, offering him options for the retrieval of further information semantically linked to that already obtained.
Lessard, Chantale; Contandriopoulos, André-Pierre; Beaulieu, Marie-Dominique
Despite increasing interest in health economic evaluation, investigations have shown limited use by micro (clinical) level decision-makers. A considerable amount of health decisions take place daily at the point of the clinical encounter; especially in primary care. Since every decision has an opportunity cost, ignoring economic information in family physicians' (FPs) decision-making may have a broad impact on health care efficiency. Knowledge translation of economic evaluation is often based on taken-for-granted assumptions about actors' interests and interactions, neglecting much of the complexity of social reality. Health economics literature frequently assumes a rational and linear decision-making process. Clinical decision-making is in fact a complex social, dynamic, multifaceted process, involving relationships and contextual embeddedness. FPs are embedded in complex social networks that have a significant impact on skills, attitudes, knowledge, practices, and on the information being used. Because of their socially constructed nature, understanding preferences, professional culture, practices, and knowledge translation requires serious attention to social reality. There has been little exploration by health economists of whether the problem may be more fundamental and reside in a misunderstanding of the process of decision-making. There is a need to enhance our understanding of the role of economic evaluation in decision-making from a disciplinary perspective different than health economics. This paper argues for a different conceptualization of the role of economic evaluation in FPs' decision-making, and proposes Bourdieu's sociological theory as a research framework. Bourdieu's theory of practice illustrates how the context-sensitive nature of practice must be understood as a socially constituted practical knowledge. The proposed approach could substantially contribute to a more complex understanding of the role of economic evaluation in FPs' decision-making
Phillips, Susan D.; And Others
Examined the role of rational, intuitive, and dependent decisional strategies in facilitating decisions about postcollege occupation among college students (N=71). Results indicated that the use of a dependent decision-making style was the single most powerful predictor of progress. (LLL)
Dacks, Penny A; Andrieu, Sandrine; Blacker, Deborah; Carman, Aaron J; Green, Allan M; Grodstein, Francine; Henderson, Victor W; James, Bryan D; Lane, Rachel F; Lau, Joseph; Lin, Pei-Jung; Reeves, Barnaby C; Shah, Raj C; Vellas, Bruno; Yaffe, Kristine; Yurko-Mauro, Karin; Shineman, Diana W; Bennett, David A; Fillit, Howard M
Worldwide, over 35 million people suffer from Alzheimer's disease and related dementias. This number is expected to triple over the next 40 years. How can we improve the evidence supporting strategies to reduce the rate of dementia in future generations? The risk of dementia is likely influenced by modifiable factors such as exercise, cognitive activity, and the clinical management of diabetes and hypertension. However, the quality of evidence is limited and it remains unclear whether specific interventions to reduce these modifiable risk factors can, in turn, reduce the risk of dementia. Although randomized controlled trials are the gold-standard for causality, the majority of evidence for long-term dementia prevention derives from, and will likely continue to derive from, observational studies. Although observational research has some unavoidable limitations, its utility for dementia prevention might be improved by, for example, better distinction between confirmatory and exploratory research, higher reporting standards, investment in effectiveness research enabled by increased data-pooling, and standardized exposure and outcome measures. Informed decision-making by the general public on low-risk health choices that could have broad potential benefits could be enabled by internet-based tools and decision-aids to communicate the evidence, its quality, and the estimated magnitude of effect.
Mohamad, Shahriari; Aliandrina, Dessy; Feng, Yan
The aim of this paper was to identify human errors in decision making process. The study was focused on a research question such as: what could be the human error as a potential of decision failure in evaluation of the alternatives in the process of decision making. Two case studies were selected from the literature and analyzed to find the human errors contribute to decision fail. Then the analysis of human errors was linked with mental models in evaluation of alternative step. The results o...
Uy, Raymonde Charles; Sarmiento, Raymond Francis; Gavino, Alex; Fontelo, Paul
Clinical decision-making involves the interplay between cognitive processes and physicians' perceptions of confidence in the context of their information-seeking behavior. The objectives of the study are: to examine how these concepts interact, to determine whether physician confidence, defined in relation to information need, affects clinical decision-making, and if information access improves decision accuracy. We analyzed previously collected data about resident physicians' perceptions of information need from a study comparing abstracts and full-text articles in clinical decision accuracy. We found that there is a significant relation between confidence and accuracy (φ=0.164, p<0.01). We also found various differences in the alignment of confidence and accuracy, demonstrating the concepts of underconfidence and overconfidence across years of clinical experience. Access to online literature also has a significant effect on accuracy (p<0.001). These results highlight possible CDSS strategies to reduce medical errors.
Keene, Claire M; Kong, Victor Y; Clarke, Damian L; Brysiewicz, Petra
Recording vital signs is important in the hospital setting and the quality of this documentation influences clinical decision making. The Modified Early Warning Score (MEWS) uses vital signs to categorise the severity of a patient's physiological derangement and illustrates the clinical impact of vital signs in detecting patient deterioration and making management decisions. This descriptive study measured the quality of vital sign recordings in an acute care trauma setting, and used the MEWS to determine the impact the documentation quality had on the detection of physiological derangements and thus, clinical decision making. Vital signs recorded by the nursing staff of all trauma patients in the acute care trauma wards at a regional hospital in South Africa were collected from January 2013 to February 2013. Investigator-measured values taken within 2 hours of the routine observations and baseline patient information were also recorded. A MEWS for each patient was calculated from the routine and investigator-measured observations. Basic descriptive statistics were performed using EXCEL. The details of 181 newly admitted patients were collected. Completion of recordings was 81% for heart rate, 88% for respiratory rate, 98% for blood pressure, 92% for temperature and 41% for GCS. The recorded heart rate was positively correlated with the investigator's measurement (Pearson's correlation coefficient of 0.76); while the respiratory rate did not correlate (Pearson's correlation coefficient of 0.02). In 59% of patients the recorded respiratory rate (RR) was exactly 20 breaths per minute and 27% had a recorded RR of exactly 15. Seven percent of patients had aberrant Glasgow Coma Scale readings above the maximum value of 15. The average MEWS was 2 for both the recorded (MEWS(R)) and investigator (MEWS(I)) vitals, with the range of MEWS(R) 0-7 and MEWS(I) 0-9. Analysis showed 59% of the MEWS(R) underestimated the physiological derangement (scores were lower than the MEWS
Kuhns, L.R.; Thornbury, J.
The authors present a collection of clinical problems, organized by organ system and disease. This book demonstrates the relative advantages and disadvantages by means of a formula for disease prevalence and the sensitivity and specificity of the tests used. The gold standard for diagnosis fo each disease is included. Relative costs, radiation dosimetry, and risks are featured
Zizzo, Natalie; Bell, Emily; Lafontaine, Anne-Louise; Racine, Eric
Patient-centred care is a recommended model of care for Parkinson's disease (PD). It aims to provide care that is respectful and responsive to patient preferences, values and perspectives. Provision of patient-centred care should entail considering how patients want to be involved in their care. To understand the participation preferences of patients with PD from a patient-centred care clinic in health-care decision-making processes. Mixed-methods study with early-stage Parkinson's disease patients from a patient-centred care clinic. Study involved a modified Autonomy Preference Index survey (N=65) and qualitative, semi-structured in-depth interviews, analysed using thematic qualitative content analysis (N=20, purposefully selected from survey participants). Interviews examined (i) the patient preferences for involvement in health-care decision making; (ii) patient perspectives on the patient-physician relationship; and (iii) patient preferences for communication of information relevant to decision making. Preferences for participation in decision making varied between individuals and also within individuals depending on decision type, relational and contextual factors. Patients had high preferences for communication of information, but with acknowledged limits. The importance of communication in the patient-physician relationship was emphasized. Patient preferences for involvement in decision making are dynamic and support shared decision making. Relational autonomy corresponds to how patients envision their participation in decision making. Clinicians may need to assess patient preferences on an on-going basis. Our results highlight the complexities of decision-making processes. Improved understanding of individual preferences could enhance respect for persons and make for patient-centred care that is truly respectful of individual patients' wants, needs and values. © 2016 The Authors. Health Expectations Published by John Wiley & Sons Ltd.
Andersen, Jens Enevold Thaulov
. These discrepancies are very unfortunate because erroneous conclusions may arise from an otherwise meticulous and dedicated effort of research staff. This may eventually lead to unreliable conclusions thus jeopardizing investigations of environmental monitoring, climate changes, food safety, clinical chemistry......It has been long recognized that results of analytical chemistry are not flawless, owing to the fact that professional laboratories and research laboratories analysing the same type of samples by the same type of instruments are likely to obtain significantly different results. The European......, forensics and other fields of science where analytical chemistry is the key instrument of decision making. In order to elucidate the potential origin of the statistical variations found among laboratories, a major program was undertaken including several analytical technologies where the purpose...
Tonry, Claire L
Prostate Cancer (PCa) is the second most commonly diagnosed cancer in men worldwide. Although increased expression of prostate-specific antigen (PSA) is an effective indicator for the recurrence of PCa, its intended use as a screening marker for PCa is of considerable controversy. Recent research efforts in the field of PCa biomarkers have focused on the identification of tissue and fluid-based biomarkers that would be better able to stratify those individuals diagnosed with PCa who (i) might best receive no treatment (active surveillance of the disease); (ii) would benefit from existing treatments; or (iii) those who are likely to succumb to disease recurrence and\\/or have aggressive disease. The growing demand for better prostate cancer biomarkers has coincided with the development of improved discovery and evaluation technologies for multiplexed measurement of proteins in bio-fluids and tissues. This review aims to (i) provide an overview of these technologies as well as describe some of the candidate PCa protein biomarkers that have been discovered using them; (ii) address some of the general limitations in the clinical evaluation and validation of protein biomarkers; and (iii) make recommendations for strategies that could be adopted to improve the successful development of protein biomarkers to deliver improvements in personalized PCa patient decision making.
Claire L. Tonry
Full Text Available Prostate Cancer (PCa is the second most commonly diagnosed cancer in men worldwide. Although increased expression of prostate-specific antigen (PSA is an effective indicator for the recurrence of PCa, its intended use as a screening marker for PCa is of considerable controversy. Recent research efforts in the field of PCa biomarkers have focused on the identification of tissue and fluid-based biomarkers that would be better able to stratify those individuals diagnosed with PCa who (i might best receive no treatment (active surveillance of the disease; (ii would benefit from existing treatments; or (iii those who are likely to succumb to disease recurrence and/or have aggressive disease. The growing demand for better prostate cancer biomarkers has coincided with the development of improved discovery and evaluation technologies for multiplexed measurement of proteins in bio-fluids and tissues. This review aims to (i provide an overview of these technologies as well as describe some of the candidate PCa protein biomarkers that have been discovered using them; (ii address some of the general limitations in the clinical evaluation and validation of protein biomarkers; and (iii make recommendations for strategies that could be adopted to improve the successful development of protein biomarkers to deliver improvements in personalized PCa patient decision making.
Baker-Ericzén, Mary J; Jenkins, Melissa M; Park, Soojin; Garland, Ann F
Mental health professionals' decision-making practice is an area of increasing interest and importance, especially in the pediatric research and clinical communities. The present study explored the role of prior training in evidence-based treatments on clinicians' assessment and treatment formulations using case vignettes. Specifically, study aims included using the Naturalistic Decision Making (NDM) cognitive theory to 1) examine potential associations between EBT training and decision-making processes (novice versus expert type), and 2) explore how client and family contextual information affects clinical decision-making. Forty-eight clinicians across two groups (EBT trained=14, Not EBT trained=34) participated. Clinicians were comparable on professional experience, demographics, and discipline. The quasi-experimental design used an analog "think aloud" method where clinicians read case vignettes about a child with disruptive behavior problems and verbalized case conceptualization and treatment planning out-loud. Responses were coded according to NDM theory. MANOVA results were significant for EBT training status such that EBT trained clinicians' displayed cognitive processes more closely aligned with "expert" decision-makers and non-EBT trained clinicians' decision processes were more similar to "novice" decision-makers, following NDM theory. Non-EBT trained clinicians assigned significantly more diagnoses, provided less detailed treatment plans and discussed fewer EBTs. Parent/family contextual information also appeared to influence decision-making. This study offers a preliminary investigation of the possible broader impacts of EBT training and potential associations with development of expert decision-making skills. Targeting clinicians' decision-making may be an important avenue to pursue within dissemination-implementation efforts in mental health practice.
... For Teens: How to Make Healthy Decisions About Sex Page Content Article Body Before you decide to ... alcohol or use drugs. Are You Ready for Sex? Sex can change your life and relationships. Having ...
.... The separation of psychology into sub-disciplines or paradigms that don't talk to one another. 3. The failure to distinguish between technical and common language usage when dealing with concepts such as decision making and command...
Full Text Available Price decision making in a marketing program framework creatings is a complicated and delicated part of marketing management, especially to keep in sight culminating of mass external factors. In a market economies price policy as a marketing mix instrument rarely is regulated by the law, which opening the ethical aspect questions of price decision making process. The ethics in the price decision making means consideration of the inner law of the individual (marketing managers and/or consumers, whose irreverence does not entail any juridical sanctions, rather its application is sanctioned by the self - awareness. The acception and stability of the ethical aspect price decision making are determined by the characteristic of selected marketing environment.
Ong, D; Khaddaj, Souheil; Bashroush, Rabih
Most intelligent systems have some form of \\ud decision making mechanisms built into their \\ud organisations. These normally include a logical \\ud reasoning element into their design. This paper reviews \\ud and compares the different logical reasoning strategies, \\ud and tries to address the accuracy and precision of \\ud decision making by formulating a tolerance to \\ud imprecision view which can be used in conjunction with \\ud the various reasoning strategies.
Homberg, Judith R
Serotonin (5-HT) is an important player in decision making. Serotonergic antidepressant, anxiolytic and antipsychotic drugs are extensively used in the treatment of neuropsychiatric disorders characterized by impaired decision making, and exert both beneficial and harmful effects in patients. Detailed insight into the serotonergic mechanisms underlying decision making is needed to strengthen the first and weaken the latter. Although much remains to be done to achieve this, accumulating studies begin to deliver a coherent view. Thus, high central 5-HT levels are generally associated with improved reversal learning, improved attentional set shifting, decreased delay discounting, and increased response inhibition, but a failure to use outcome representations. Based on 5-HT's evolutionary role, I hypothesize that 5-HT integrates expected, or changes in, relevant sensory and emotional internal/external information, leading to vigilance behaviour affecting various decision making processes. 5-HT receptor subtypes play distinctive roles in decision making. 5-HT(2A) agonists and 5-HT2c antagonists decrease compulsivity, whereas 5-HT(2A) antagonists and 5-HT(2C) agonists decrease impulsivity. 5-HT(6) antagonists univocally affect decision making processes. Copyright © 2011 Elsevier Ltd. All rights reserved.
Asiedu, Gladys B; Ridgeway, Jennifer L; Carroll, Katherine; Jatoi, Aminah; Radecki Breitkopf, Carmen
This study employs the concept of relational autonomy to understand how relational encounters with family members (FMs) and care providers may shape decisions around ovarian cancer patients' clinical trial (CT) participation. The study also offers unique insights into how FMs view patients' decision making. In-depth interviews were conducted with 33 patients with ovarian cancer who had been offered a CT and 39 FMs. Data were inductively analysed using a thematic approach and deductively informed by constructs derived from the theory of relational autonomy (RA). Patients' relationships, experiences and social status were significant resources that shaped their decisions. Patients did not give equal weight to all relationships and created boundaries around whom to include in decision making. Doctors' recommendations and perceived enthusiasm were described as influential in CT decisions. Both patients with ovarian cancer and their FMs maintained that patients have the "final say," indicating an individualistic autonomy. However, maintaining the "final say" in the decision-making process is constitutive of patients' relationships, emphasizing a relational approach to autonomy. FMs support patients' autonomy and they do so particularly when they believe the patient is capable of making the right choices. Although ethical principles underlying informed consent for CT participation emphasize individual autonomy, greater attention to relational autonomy is warranted for a more comprehensive understanding of CT decision making. © 2018 Mayo Clinic. Health Expectations published by John Wiley & Sons Ltd.
Marewski, Julian N.; Gigerenzer, Gerd
Can less information be more helpful when it comes to making medical decisions? Contrary to the common intuition that more information is always better, the use of heuristics can help both physicians and patients to make sound decisions. Heuristics are simple decision strategies that ignore part of the available information, basing decisions on only a few relevant predictors. We discuss: (i) how doctors and patients use heuristics; and (ii) when heuristics outperform information-greedy methods, such as regressions in medical diagnosis. Furthermore, we outline those features of heuristics that make them useful in health care settings. These features include their surprising accuracy, transparency, and wide accessibility, as well as the low costs and little time required to employ them. We close by explaining one of the statistical reasons why heuristics are accurate, and by pointing to psychiatry as one area for future research on heuristics in health care. PMID:22577307
Marewski, Julian N; Gigerenzer, Gerd
Can less information be more helpful when it comes to making medical decisions? Contrary to the common intuition that more information is always better, the use of heuristics can help both physicians and patients to make sound decisions. Heuristics are simple decision strategies that ignore part of the available information, basing decisions on only a few relevant predictors. We discuss: (i) how doctors and patients use heuristics; and (ii) when heuristics outperform information-greedy methods, such as regressions in medical diagnosis. Furthermore, we outline those features of heuristics that make them useful in health care settings. These features include their surprising accuracy, transparency, and wide accessibility, as well as the low costs and little time required to employ them. We close by explaining one of the statistical reasons why heuristics are accurate, and by pointing to psychiatry as one area for future research on heuristics in health care.
Abboudi, Hamid; Ahmed, Kamran; Normahani, Pasha; Abboudi, May; Kirby, Roger; Challacombe, Ben; Khan, Mohammed Shamim; Dasgupta, Prokar
Non-technical skills are important behavioural aspects that a urologist must be fully competent at to minimise harm to patients. The majority of surgical errors are now known to be due to errors in judgment and decision making as opposed to the technical aspects of the craft. The authors reviewed the published literature regarding decision-making theory and in practice related to urology as well as the current tools available to assess decision-making skills. Limitations include limited number of studies, and the available studies are of low quality. Decision making is the psychological process of choosing between alternative courses of action. In the surgical environment, this can often be a complex balance of benefit and risk within a variable time frame and dynamic setting. In recent years, the emphasis of new surgical curriculums has shifted towards non-technical surgical skills; however, the assessment tools in place are far from objective, reliable and valid. Surgical simulators and video-assisted questionnaires are useful methods for appraisal of trainees. Well-designed, robust and validated tools need to be implemented in training and assessment of decision-making skills in urology. Patient safety can only be ensured when safe and effective decisions are made.
Phua, J; See, K C; Khalizah, H J; Low, S P; Lim, T K
Clinical questions often arise at daily hospital bedside rounds. Yet, little information exists on how the search for answers may be facilitated. The aim of this prospective study was, therefore, to evaluate the overall utility, including the feasibility and usefulness of incorporating searches of UpToDate, a popular online information resource, into rounds. Doctors searched UpToDate for any unresolved clinical questions during rounds for patients in general medicine and respiratory wards, and in the medical intensive care unit of a tertiary teaching hospital. The nature of the questions and the results of the searches were recorded. Searches were deemed feasible if they were completed during the rounds and useful if they provided a satisfactory answer. A total of 157 UpToDate searches were performed during the study period. Questions were raised by all ranks of clinicians from junior doctors to consultants. The searches were feasible and performed immediately during rounds 44% of the time. Each search took a median of three minutes (first quartile: two minutes, third quartile: five minutes). UpToDate provided a useful and satisfactory answer 75% of the time, a partial answer 17% of the time and no answer 9% of the time. It led to a change in investigations, diagnosis or management 37% of the time, confirmed what was originally known or planned 38% of the time and had no effect 25% of the time. Incorporating UpToDate searches into daily bedside rounds was feasible and useful in clinical decision-making.
Bruins, Marjan; Ruijs, G.; Wolfhagen, M.J.H.M.; Bloembergen, Peter; Aarts, Jos
Abstract Background Clinicians view the accuracy of test results and the turnaround time as the two most important service aspects of the clinical microbiology laboratory. Because of the time needed for the culturing of infectious agents, final hardcopy culture results will often be available too late to have a significant impact on early antimicrobial therapy decisions, vital in infectious disease management. The clinical microbiologist therefore reports to the clinician clinically relevant ...
Rennie, Sarah C; van Rij, Andre M; Jaye, Chrystal; Hall, Katherine H
Decision making is a key competency of surgeons; however, how best to assess decisions and decision makers is not clearly established. The aim of the present study was to identify criteria that inform judgments about surgical trainees' decision-making skills. A qualitative free text web-based survey was distributed to recognized international experts in Surgery, Medical Education, and Cognitive Research. Half the participants were asked to identify features of good decisions, characteristics of good decision makers, and essential factors for developing good decision-making skills. The other half were asked to consider these areas in relation to poor decision making. Template analysis of free text responses was performed. Twenty-nine (52%) experts responded to the survey, identifying 13 categories for judging a decision and 14 for judging a decision maker. Twelve features/characteristics overlapped (considered, informed, well timed, aware of limitations, communicated, knowledgeable, collaborative, patient-focused, flexible, able to act on the decision, evidence-based, and coherent). Fifteen categories were generated for essential factors leading to development of decision-making skills that fall into three major themes (personal qualities, training, and culture). The categories compiled from the perspectives of good/poor were predominantly the inverse of each other; however, the weighting given to some categories varied. This study provides criteria described by experts when considering surgical decisions, decision makers, and development of decision-making skills. It proposes a working definition of a good decision maker. Understanding these criteria will enable clinical teachers to better recognize and encourage good decision-making skills and identify poor decision-making skills for remediation.
Elbogen, Eric B; Fuller, Sara; Johnson, Sally C; Brooks, Stephanie; Kinneer, Patricia; Calhoun, Patrick S; Beckham, Jean C
Increased media attention to post-deployment violence highlights the need to develop effective models to guide risk assessment among military Veterans. Ideally, a method would help identify which Veterans are most at risk for violence so that it can be determined what could be done to prevent violent behavior. This article suggests how empirical approaches to risk assessment used successfully in civilian populations can be applied to Veterans. A review was conducted of the scientific literature on Veteran populations regarding factors related to interpersonal violence generally and to domestic violence specifically. A checklist was then generated of empirically-supported risk factors for clinicians to consider in practice. To conceptualize how these known risk factors relate to a Veteran's violence potential, risk assessment scholarship was utilized to develop an evidence-based method to guide mental health professionals. The goals of this approach are to integrate science into practice, overcome logistical barriers, and permit more effective assessment, monitoring, and management of violence risk for clinicians working with Veterans, both in Department of Veteran Affairs settings and in the broader community. Research is needed to test the predictive validity of risk assessment models. Ultimately, the use of a systematic, empirical framework could lead to improved clinical decision-making in the area of risk assessment and potentially help prevent violence among Veterans. Published by Elsevier Ltd.
Maifeld, Michelle; Hahn, Sandra; Titler, Marita G; Mullen, Meredithe
To identify salient variables that influence decision making regarding multifetal reduction (MFR) and describe their effect on individuals over time. Prospective, exploratory, descriptive design, using qualitative and quantitative methods. Midwestern tertiary care center. A convenience sample of 11 consecutive consenting couples with triplet or higher-order pregnancies who elected to undergo MFR. Semistructured audiotaped telephone interviews at three points: (a) 2 weeks postreduction, (b) 6 weeks postpartum, and (c) 6 months postpartum; a demographic and marital adjustment questionnaire. Themes identified by content analysis and compared via matrix analysis between males and females and at three points in time; trends in marital adjustment. Dominant variables influencing MFR decision making were risks associated with higher-order pregnancies and preservation of infants' and mothers' health. Most participants identified emotional issues, including moral and ethical dilemmas, as the most difficult aspect of reduction. Over time, participants reported feeling more positive about their decision; nonetheless, negative feelings emerged progressively. Risk aversion favored MFR decision making. Yet, both making and living with the decision were emotionally difficult for this sample. Interventions are needed to assist couples with this decision and its consequences.
Holmberg, J.; Pulkkinen, U.
The Technical Research Centre of Finland (VTT) has studied with the Finnish Centre for Radiation and Nuclear Safety (STUK) the applicability of decision analytic approach to the treatment of nuclear safety related problems at the regulatory body. The role of probabilistic safety assessment (PSA) in decision making has also been discussed. In the study, inspectors from STUK exercised with a decision analytic approach by reoperationalizing two occurred and solved problems. The research scientist from VTT acted as systems analysts guiding the analysis process. The first case was related to a common cause failure phenomenon in solenoid valves controlling pneumatic valves important to safety of the plant. The problem of the regulatory body was to judge whether to allow continued operation or to require more detailed inspections and in which time chedule the inspections should be done. The latter problem was to evaluate design changes of external electrical grid connections after a fire incident had revealed weakness in the separation of electrical system. In both cases, the decision analysis was carried out several sessions in which decision makers, technical experts as well as experts of decision analysis participated. A multi-attribute value function was applied as a decision model so that attributes had to be defined to quantify the levels of achievements of the objectives. The attributes included both indicators related to the level of operational safety of the plant such as core damage frequency given by PSA, and indicators related to the safety culture, i.e., how well the chosen option fits on the regulatory policy. (24 refs., 6 figs., 9 tabs.)
Rosenbloom, Michael H; Schmahmann, Jeremy D; Price, Bruce H
Decision-making is a complex executive function that draws on past experience, present goals, and anticipation of outcome, and which is influenced by prevailing and predicted emotional tone and cultural context. Functional imaging investigations and focal lesion studies identify the orbitofrontal, anterior cingulate, and dorsolateral prefrontal cortices as critical to decision-making. The authors review the connections of these prefrontal regions with the neocortex, limbic system, basal ganglia, and cerebellum, highlight current ideas regarding the cognitive processes of decision-making that these networks subserve, and present a novel integrated neuroanatomical model for decision-making. Finally, clinical relevance of this circuitry is illustrated through a discussion of frontotemporal dementia, traumatic brain injury, and sociopathy.
Runge, Michael C.; Grand, James B.; Mitchell, Michael S.; Krausman, Paul R.; Cain, James W. III
Wildlife management is a decision-focused discipline. It needs to integrate traditional wildlife science and social science to identify actions that are most likely to achieve the array of desires society has surrounding wildlife populations. Decision science, a vast field with roots in economics, operations research, and psychology, offers a rich set of tools to help wildlife managers frame, decompose, analyze, and synthesize their decisions. The nature of wildlife management as a decision science has been recognized since the inception of the field, but formal methods of decision analysis have been underused. There is tremendous potential for wildlife management to grow further through the use of formal decision analysis. First, the wildlife science and human dimensions of wildlife disciplines can be readily integrated. Second, decisions can become more efficient. Third, decisions makers can communicate more clearly with stakeholders and the public. Fourth, good, intuitive wildlife managers, by explicitly examining how they make decisions, can translate their art into a science that is readily used by the next generation.
Stephanie Ying-Fen Chen
Full Text Available Two experiments investigated how category information is used in decision making under uncertainty and whether the framing of category information influences how it is used. Subjects were presented with vignettes in which the categorization of a critical item was ambiguous and were asked to choose among a set of actions with the goal of attaining the desired outcome for the main character in the story. The normative decision making strategy was to base the decision on all possible categories; however, research on a related topic, category-based induction, has found that people often only consider a single category when making predictions when categorization is uncertain. These experiments found that subjects tend to consider multiple categories when making decisions, but do so both when it is and is not appropriate, suggesting that use of multiple categories is not driven by an understanding of what categories are and are not relevant to the decision. Similarly, although a framing manipulation increased the rate of multiple-category use, it did so in situations in which multiple-category use was and was not appropriate.
Full Text Available One of the leading descriptive theories of decision-making under risk, Tversky & Kahneman's Prospect theory, reveals that normative explanation of decisionmaking, based only on principle of maximizing outcomes expected utility, is unsustainable. It also underlines the effect of alternative factors on decision-making. Framing effect relates to an influence that verbal formulation of outcomes has on choosing between certain and risky outcomes; in negative frame people tend to be risk seeking, whereas in positive frame people express risk averse tendencies. Individual decisions are not based on objective probabilities of outcomes, but on subjective probabilities that depend on outcome desirability. Unrealistically pessimistic subjects assign lower probabilities (than the group average to the desired outcomes, while unrealistically optimistic subjects assign higher probabilities (than the group average to the desired outcomes. Experiment was conducted in order to test the presumption that there's a relation between unrealistic optimism and decision-making under risk. We expected optimists to be risk seeking, and pessimist to be risk averse. We also expected such cognitive tendencies, if they should become manifest, to be framing effect resistant. Unrealistic optimism scale was applied, followed by the questionnaire composed of tasks of decision-making under risk. Results within the whole sample, and results of afterwards extracted groups of pessimists and optimists both revealed dominant risk seeking tendency that is resistant to the influence of subjective probabilities as well as to the influence of frame in which the outcome is presented.
Jane, Nancy Yesudhas; Nehemiah, Khanna Harichandran; Arputharaj, Kannan
Clinical time-series data acquired from electronic health records (EHR) are liable to temporal complexities such as irregular observations, missing values and time constrained attributes that make the knowledge discovery process challenging. This paper presents a temporal rough set induced neuro-fuzzy (TRiNF) mining framework that handles these complexities and builds an effective clinical decision-making system. TRiNF provides two functionalities namely temporal data acquisition (TDA) and temporal classification. In TDA, a time-series forecasting model is constructed by adopting an improved double exponential smoothing method. The forecasting model is used in missing value imputation and temporal pattern extraction. The relevant attributes are selected using a temporal pattern based rough set approach. In temporal classification, a classification model is built with the selected attributes using a temporal pattern induced neuro-fuzzy classifier. For experimentation, this work uses two clinical time series dataset of hepatitis and thrombosis patients. The experimental result shows that with the proposed TRiNF framework, there is a significant reduction in the error rate, thereby obtaining the classification accuracy on an average of 92.59% for hepatitis and 91.69% for thrombosis dataset. The obtained classification results prove the efficiency of the proposed framework in terms of its improved classification accuracy.
Leatherman, Martha E; Goethe, Katherine E
The goal of this column is to help experienced clinicians navigate the judicial system when they are confronted with requests for capacity evaluations that involve guardianship (conservatorship). The interface between the growing elderly medical population and increasing requests for substituted decision making is becoming more complex. This column will help practicing psychiatrists understand the medical, legal, and societal factors involved in adult guardianship. Such understanding is necessary in order to effectively perform guardianship evaluations and adequately inform courts, patients, and families about the psychiatric diagnoses central to substituted decision making.
SM Turpin; MA Marais
This paper compares a number of theoretical models of decision-making with the way in which senior managers make decisions in practice. Six prominent decision-makers were interviewed about their own decision-making style, as well as their use of decision support technology. Significant variation was found in personal decision-making styles. However, some central themes emerged, such as the importance of sensitivity to the decision-making context, attention to the presentation of information, ...
The Iowa Gambling Task (IGT) measures affective decision making and has revealed decision making impairments across a wide range of eating disorders. This study aimed to investigate affective decision making in severely obese individuals.
exploration and elaboration of both rational and intuitive decision making processes. In addition, emotions may also play an important role in...More specifically, it suggests that both rational and intuitive decision making processes are likely to play an important role in ethical decision ...and military literature related to ethical decision making more generally. Specifically, it suggests that both rational and intuitive decision making
Stallinga, Gonda; Roodbol, Petrie; Annema, Coby; Jansen, Gerard; Wynia, Klaske
Aims and objectives. To compare a functioning assessment based on the International Classification of Functioning, Disability and Health (ICF) with a conventional medical assessment, in terms of their respective consequences for health professionals’ clinical decision-making and the fit with
Stallinga, Hillegonda A.; Roodbol, Petrie F.; Annema, Coby; Jansen, Gerard J.; Wynia, Klaske
Aims and objectives. To compare a functioning assessment based on the International Classification of Functioning, Disability and Health (ICF) with a conventional medical assessment, in terms of their respective consequences for health professionals' clinical decision-making and the fit with
Baker-Ericzén, Mary J.; Jenkins, Melissa M.; Park, Soojin; Garland, Ann F.
Background: Mental health professionals' decision-making practice is an area of increasing interest and importance, especially in the pediatric research and clinical communities. Objective: The present study explored the role of prior training in evidence-based treatments (EBTs) on clinicians' assessment and treatment formulations using…
Thackray, Debbie; Roberts, Lisa
The ability of physiotherapists to make clinical decisions is a vital component of being an autonomous practitioner, yet this complex phenomenon has been under-researched in cardiorespiratory physiotherapy. The purpose of this study was to explore clinical decision-making (CDM) by experienced physiotherapists in a scenario of a simulated patient experiencing acute deterioration of their respiratory function. The main objective of this observational study was to identify the actions, thoughts, and behaviours used by experienced cardiorespiratory physiotherapists in their clinical decision-making processes. A mixed-methods (qualitative) design employing observation and think-aloud, was adopted using a computerised manikin in a simulated environment. The participants clinically assessed the manikin programmed with the same clinical signs, under standardised conditions in the clinical skills practice suite, which was set up as a ward environment. Experienced cardiorespiratory physiotherapists, recruited from clinical practice within a 50-mile radius of the University(*). Participants were video-recorded throughout the assessment and treatment and asked to verbalise their thought processes using the 'think-aloud' method. The recordings were transcribed verbatim and managed using a Framework approach. Eight cardiorespiratory physiotherapists participated (mean 7years clinical experience, range 3.5-16years. CDM was similar to the collaborative hypothetico-deductive model, five-rights nursing model, reasoning strategies, inductive reasoning and pattern recognition. However, the CDM demonstrated by the physiotherapists was complex, interactive and iterative. Information processing occurred continuously throughout the whole interaction with the patient, and the specific cognitive skills of recognition, matching, discriminating, relating, inferring, synthesising and prediction were identified as being used sequentially. The findings from this study were used to develop a new
Presented is an outline of a college course, "Education in American Society," that focused on teaching students rational decision-making skills while examining current issues in American Education. The outline is followed by student comments, reactions, and evaluations of the course. (JMD)
This thesis consists of five projects in three topics with a shared theme of understanding cellular decision-making processes with mathematical modeling. In the first topic, we address the possible interaction between bacterial Toxin-Antitoxin (TA) systems and stringent response alarmone guanosin...
de la Rosa, Leonidas Enrique
If our decision-making processes are to some extent shaped by evolutionary pressures and our environment is different from that to which we adapted, some of our choices will not be in our best interest. But revealed preference is the only tool that we have so far to conduct a normative analysis...
Full Text Available Each of us makes a number of decisions, from the less important to those with far-reaching consequences. As members of different groups, we are also actors of group decision making. In order to make a rational decision, a choice-making procedure must satisfy a number of assumptions (conditions of rationality. In addition, when it comes to group decisions, those procedures should also be “fair.” However, it is not possible to define a procedure of choice-making that would transform individual orders of alternatives based on preferences of perfectly rational individuals into a single social order and still meet conditions of rationality and ethics. The theory of deliberative democracy appeared in response to the impossibility of Social Choice theory. The basic assumption of deliberative democracy is that individuals adjust their preferences taking into account interests of the community. They are open for discussion with other group members and are willing to change their attitudes in order to achieve common interests. Ideally, group members come to an agreement during public discussion (deliberation. Still, this concept cannot completely overcome all the difficulties posed by the theory of social choice. Specifically, there is no solution for strategic and manipulative behavior of individuals. Also, the concept of deliberative democracy faces certain problems particular to this approach, such as, to name but a few, problems with the establishment of equality of participants in the debate and their motivation, as well as problems with the organization of public hearings. [Projekat Ministarstva nauke Republike Srbije, br. 47009: Evropske integracije i društveno-ekonomske promene privrede Srbije na putu ka EU i br. 179015: Izazovi i perspektive strukturnih promena u Srbiji: Strateški pravci ekonomskog razvoja i usklađivanje sa zahtevima EU
Mastitis remains one of the most common diseases of dairy cows and represents a large economic loss to the industry as well as a considerable welfare issue to the cows affected. Decisions are routinely made about the treatment and control of mastitis despite evidence being sparse regarding the likely consequences in terms of clinical efficacy and return on investment. The aim of this thesis was to enhance decision making around the treatment and prevention of mastitis using probabilistic meth...
Holdar, Ulrika; Wallin, Lars; Heiwe, Susanne
Despite the current movement for health-care to become more informed by evidence, knowledge on effective implementation of evidence-based practice is scarce. To improve research application among physiotherapists, the process of implementation and clinical reasoning needs to be scrutinized. The aim of this study was to identify various experiences of factors that influence the physiotherapist's clinical reasoning in specialist care. A phenomenographic approach was chosen. Eleven physiotherapists at two acute care hospitals in nn. Data was obtained by observations and interviews. Phenomenographic data analysis identified various experiences of clinical decision-making. The Ethical Review Board of the nn approved the study. The observations and the interviews enabled identification of various experiences that influenced clinical decision-making. The physiotherapists' clinical reasoning was perceived to be constrained by contextual factors. The physiotherapists collected current information on the patient by using written and verbal information exchange and used this to generate an inner picture of the patient. By creating hypotheses that were accepted or rejected, they made decisions in advance of their interventions. The decisions were influenced by the individual characteristics of the physiotherapist, his/her knowledge and patient perceptions. Clinical reasoning is a complex and constantly evolving process. Contextual factors such as economy and politics are not easily changed, but factors such as the patient and the physiotherapist as a person are more tangible. Copyright © 2013 John Wiley & Sons, Ltd.
Elwyn, Glyn; Pickles, Tim; Edwards, Adrian; Kinsey, Katharine; Brain, Kate; Newcombe, Robert G; Firth, Jill; Marrin, Katy; Nye, Alan; Wood, Fiona
To evaluate whether introducing tools, specifically designed for use in clinical encounters, namely Option Grids, into a clinical practice setting leads to higher levels of shared decision making. A stepped wedge trial design where 6 physiotherapists at an interface clinic in Oldham, UK, were sequentially instructed in how to use an Option Grid for osteoarthritis of the knee. Patients with suspected or confirmed osteoarthritis of the knee were recruited, six per clinician prior to instruction, and six per clinician afterwards. We measured shared decision making, patient knowledge, and readiness to decide. A total of 72 patients were recruited; 36 were allocated to the intervention group. There was an 8.4 point (95% CI 4.4 to 12.2) increase in the Observer OPTION score (range 0-100) in the intervention group. The mean gain in knowledge was 0.9 points (score range 0-5, 95% CI, 0.3 to 1.5). There was no increase in encounter duration. Shared decision making increased when clinicians used the knee osteoarthritis Option Grid. Tools designed to support collaboration and deliberation about treatment options lead to increased levels of shared decision making. Copyright © 2015 The Authors. Published by Elsevier Ireland Ltd.. All rights reserved.
Thompson, Jonathan; Yoward, Samantha; Dawson, Pamela
Physiotherapy extended scope practitioner (ESP) roles are widely utilized in the management of musculoskeletal conditions. The present article reviews the current literature, with particular emphasis on the decision-making process, patient/clinician interaction and clinical outcomes. A systematic review of musculoskeletal extended scope practice was carried out. The review focused on the outcome of interventions, and the interactions and decision-making processes between ESPs and their patients. A wide search strategy was employed, through multiple databases, grey literature and experts in the field. Qualitative and quantitative studies alike were included and a mixed-methods synthesis approach was undertaken in analysing the findings of included studies. A total of 476 articles were identified for inclusion, 25 of which (22 quantitative and three qualitative) meeting the criteria for full quality appraisal and synthesis. It was not possible to conduct a meta-analysis owing to data heterogeneity. The results showed high patient satisfaction with the ESP role, support for ESP staff listing patients for orthopaedic surgery, a high positive correlation of decision making between ESPs and orthopaedic surgeons and evidence of a positive impact on patient outcomes. Qualitative themes reflected the importance of ESP clinical decision making and interpersonal skills and their role in patient education. There is broad support for the physiotherapy ESP role and evidence of favourable outcomes from ESP intervention. Clinical decisions made by ESPs correlate well with those of medical colleagues, although there is a lack of detail explaining the ESP decision-making process itself and the influences and mechanisms by which this occurs. Copyright © 2016 John Wiley & Sons, Ltd. Copyright © 2016 John Wiley & Sons, Ltd.
Shakespeare, Thomas P.; Back, Michael F.; Lu, Jiade J.; Lee, Khai Mun; Mukherjee, Rahul K.
Purpose: The external audit of oncologist clinical practice is increasingly important because of the incorporation of audits into national maintenance of certification (MOC) programs. However, there are few reports of external audits of oncology practice or decision making. Our institution (The Cancer Institute, Singapore) was asked to externally audit an oncology department in a developing Asian nation, providing a unique opportunity to explore the feasibility of such a process. Methods and Materials: We audited 100 randomly selected patients simulated for radiotherapy in 2003, using a previously reported audit instrument assessing clinical documentation/quality assurance and medical decision making. Results: Clinical documentation/quality assurance, decision making, and overall performance criteria were adequate 74.4%, 88.3%, and 80.2% of the time, respectively. Overall 52.0% of cases received suboptimal management. Multivariate analysis revealed palliative intent was associated with improved documentation/clinical quality assurance (p = 0.07), decision making (p 0.007), overall performance (p = 0.003), and optimal treatment rates (p 0.07); non-small-cell lung cancer or central nervous system primary sites were associated with better decision making (p = 0.001), overall performance (p = 0.03), and optimal treatment rates (p = 0.002). Conclusions: Despite the poor results, the external audit had several benefits. It identified learning needs for future targeting, and the auditor provided facilitating feedback to address systematic errors identified. Our experience was also helpful in refining our national revalidation audit instrument. The feasibility of the external audit supports the consideration of including audit in national MOC programs
There is a fundamental difference between the acceptability of a civilizatory or societal risk and the acceptability of the decision-making process that leads to a civilizatory or societal risk. The analysis of individual risk decisions - regarding who, executes when which indisputably hazardous, unhealthy or dangerous behaviour under which circumstances - is not helpful in finding solutions for the political decisions at hand in Germany concerning nuclear energy in particular or energy in general. The debt for implementation of any technology, in the sense of making the technology a success in terms of broad acceptance and general utilisation, lies with the particular industry involved. Regardless of the technology, innovation research identifies the implementation phase as most critical to the success of any innovation. In this sense, nuclear technology is at best still an innovation, because the implementation has not yet been completed. Fear and opposition to innovation are ubiquitous. Even the economy - which is often described as 'rational' - is full of this resistance. Innovation has an impact on the pivotal point between stability, the presupposition for the successful execution of decisions already taken and instability, which includes insecurity, but is also necessary for the success of further development. By definition, innovations are beyond our sphere of experience; not at the level of reliability and trust yet to come. Yet they are evaluated via the simplifying heuristics for making decisions proven not only to be necessary and useful, but also accurate in the familiar. The 'settlement of the debt of implementation', the accompanying communication, the decision-making procedures concerning the regulation of averse effects of the technology, but also the tailoring of the new technology or service itself must be directed to appropriate target groups. But the group often aimed at in the nuclear debate, the group, which largely determines political
M. van der Ven (Myrthe)
markdownabstractThe _first aim_ of this thesis was to evaluate the added value of ultrasound in clinical decision making in patients with arthralgia, patients with psoriasis and monitoring RA patients. Our _second aim_ was to increase sensitivity of power Doppler ultrasound for MCP joints.
Morrison, Jeffrey G.; Kelly, Richard T.; Moore, Ronald A.; Hutchins, Susan G.
To appear in J. A. Cannon-Bowers & E. Salas (Eds.), Decision Making Under Stress: Implications for Training and Simulation. A prototype decision support system (DSS) was developed to enhance Navy tactical decision making based on naturalistic decision processes. Displays were developed to support critical decision making tasks through recognition-primed and explanation-based reasoning processes, and cognitive analysis was conducted of the decision making problems faced by Navy ...
Parsons, S.; Jennings, N. R.
This paper summarises our on-going work on mixed- initiative decision making which extends both classical decision theory and a symbolic theory of decision making based on argumentation to a multi-agent domain.
Garcia, Luiz Henrique Costa, E-mail: firstname.lastname@example.org [Associacao de Medicina Intensiva Brasileira (AMIB), Sao Paulo, SP (Brazil); Irmandade da Santa Casa de Misericordia de Sao Paulo, SP (Brazil); Ferreira, Bruna Cortez [Hospital de Base de Sao Jose do Rio Preto, SP (Brazil)
The present study was aimed at proposing a systematic evaluation of cranial computed tomography, identifying the main aspects to be analyzed in order to facilitate the decision making process regarding diagnosis and management in emergency settings. The present descriptive study comprised a literature review at the following databases: Access Medicine and Access Emergency Medicine (McGraw-Hill Education); British Medical Journal Evidence Center; UptoDate; Bireme; PubMed; Lilacs; SciELO; ProQuest; Micromedex (Thomson Reuters); Embase. Once the literature review was completed, the authors identified the main diseases with tomographic repercussions and proposed the present system to evaluate cranial computed tomography images. An easy-to-memorize ABC system will facilitate the decision making in emergency settings, as it covers the main diseases encountered by intensivists and emergency physicians, and provides a sequential guidance about anatomical structures to be investigated as well as their respective alterations. (author)
Luiz Henrique Costa Garcia
Full Text Available The present study was aimed at proposing a systematic evaluation of cranial computed tomography, identifying the main aspects to be analyzed in order to facilitate the decision making process regarding diagnosis and management in emergency settings. The present descriptive study comprised a literature review at the following databases: Access Medicine and Access Emergency Medicine (McGraw- Hill Education; British Medical Journal Evidence Center; UptoDate; Bireme; PubMed; Lilacs; SciELO; ProQuest; Micromedex (Thomson Reuters; Embase. Once the literature review was completed, the authors identified the main diseases with tomographic repercussions and proposed the present system to evaluate cranial computed tomography images. An easy-to-memorize ABC system will facilitate the decision making in emergency settings, as it covers the main diseases encountered by intensivists and emergency physicians, and provides a sequential guidance about anatomical structures to be investigated as well as their respective alterations.
Garcia, Luiz Henrique Costa; Ferreira, Bruna Cortez
The present study was aimed at proposing a systematic evaluation of cranial computed tomography, identifying the main aspects to be analyzed in order to facilitate the decision making process regarding diagnosis and management in emergency settings. The present descriptive study comprised a literature review at the following databases: Access Medicine and Access Emergency Medicine (McGraw-Hill Education); British Medical Journal Evidence Center; UptoDate; Bireme; PubMed; Lilacs; SciELO; ProQuest; Micromedex (Thomson Reuters); Embase. Once the literature review was completed, the authors identified the main diseases with tomographic repercussions and proposed the present system to evaluate cranial computed tomography images. An easy-to-memorize ABC system will facilitate the decision making in emergency settings, as it covers the main diseases encountered by intensivists and emergency physicians, and provides a sequential guidance about anatomical structures to be investigated as well as their respective alterations. (author)
Mira, José Joaquín; Guilabert, Mercedes; Pérez-Jover, Virtudes; Lorenzo, Susana
There are doubts on whether patients feel that they have sufficient information for actively participating in clinical decisions. To describe the type of information that patients receive. To determine whether patients consider this information sufficient, and whether it contributes or not to improve clinical safety. To identify the barriers for patient participation in clinical decision making. Cross-sectional study with 764 patients and 327 physicians. Fourteen health centres belonging to three primary care districts and three hospitals in Spain. Just 35.1% (268) (95% CI 32.2, 39.1%) of patients preferred to have the last word in clinical decisions. Age (39 vs. 62%, P communication by the patients. Only 19.6% (64) (95% CI 15.4, 24.2%) of doctors considered that they could intervene to involve patients in the decisions. The majority of patients prefer the decisions to be made by their doctor, especially those with more severe illnesses, and older patients. Patients are not normally informed about medication interactions, precautions and foreseeable complications. The information provided by general practitioners does not seem to contribute enough to the patient involvement in clinical safety. © 2012 John Wiley & Sons Ltd.
and Einhom (1991); Zeelenberg et al. (1997). This environmental context also makes it difficult to associate measured personality traits with specific... Zeelenberg and Beattie5 (1997): People are motivated to minimize post-decision regret. As a result people can become risk averse or risk seeking...188-201), Ablex, Norwood NJ, 1993. 5 Zeelenberg M. and J. Beattie. "Consequences of regret aversion 2: additional evidence for effects of feedback on
R F&aauml;re; S Grosskopf; D Margaritis
In this note we extend the standard DEA paradigm to address the question of how one can price DMUs (decision-making units). To do this we use an adjoint transformation to the technology generated by these DMUs which links to traditional linear programming theory of the firm and is similar to pricing portfolios in financial markets. We also provide a numerical example illustrating the practicality of the proposed method.
The studies in this thesis show that for older cancer patients, tailor-made care should be the standard of care, striking the golden mean between undertreatment and overtreatment and fully taking into account the heterogeneity of this patient population. The comprehensive geriatric assessment will provide valuable information about a patient’s overall health status, but its exact place within the decision-making process still remains to be defined.
This, P; Panel, P
When two options or more can be chosen in medical care, the final decision implies two steps: facts analysis, and patient evaluation of preferences. Shared Medical Decision-Making is a rational conceptual frame that can be used in such cases. In this paper, we describe the concept, its practical modalities, and the questions raised by its use. In gynaecology, many medical situations involve "sensitive preferences choice": for example, contraceptive choice, menorrhagia treatment, and approach of menopause. Some tools from the "Shared Medical Decision Making" concept are useful to structure medical consultations, to convey information, and to reveal patients preferences. Decision aid are used in clinical research settings, but some of them may also be easily used in usual practice, and help physicians to improve both quality and traceability of the decisional process. Copyright 2009 Elsevier Masson SAS. All rights reserved.
van Trijffel, Emiel; Plochg, Thomas; van Hartingsveld, Frank; Lucas, Cees; Oostendorp, Rob A B
Passive intervertebral motion (PIVM) assessment is a characterizing skill of manual physical therapists (MPTs) and is important for judgments about impairments in spinal joint function. It is unknown as to why and how MPTs use this mobility testing of spinal motion segments within their clinical reasoning and decision-making. This qualitative study aimed to explore and understand the role and position of PIVM assessment within the manual diagnostic process. Eight semistructured individual interviews with expert MPTs and three subsequent group interviews using manual physical therapy consultation platforms were conducted. Line-by-line coding was performed on the transcribed data, and final main themes were identified from subcategories. Three researchers were involved in the analysis process. Four themes emerged from the data: contextuality, consistency, impairment orientedness, and subjectivity. These themes were interrelated and linked to concepts of professionalism and clinical reasoning. MPTs used PIVM assessment within a multidimensional, biopsychosocial framework incorporating clinical data relating to mechanical dysfunction as well as to personal factors while applying various clinical reasoning strategies. Interpretation of PIVM assessment and subsequent decisions on manipulative treatment were strongly rooted within practitioners' practical knowledge. This study has identified the specific role and position of PIVM assessment as related to other clinical findings within clinical reasoning and decision-making in manual physical therapy in The Netherlands. We recommend future research in manual diagnostics to account for the multivariable character of physical examination of the spine.
Katahira, Kentaro; Fujimura, Tomomi; Okanoya, Kazuo; Okada, Masato
The emotional outcome of a choice affects subsequent decision making. While the relationship between decision making and emotion has attracted attention, studies on emotion and decision making have been independently developed. In this study, we investigated how the emotional valence of pictures, which was stochastically contingent on participants’ choices, influenced subsequent decision making. In contrast to traditional value-based decision-making studies that used money or food as a reward...
Kentaro eKatahira; Kentaro eKatahira; Kentaro eKatahira; Tomomi eFujimura; Tomomi eFujimura; Kazuo eOkanoya; Kazuo eOkanoya; Kazuo eOkanoya; Masato eOkada; Masato eOkada; Masato eOkada
The emotional outcome of a choice affects subsequent decision making. While the relationship between decision making and emotion has attracted attention, studies on emotion and decision making have been independently developed. In this study, we investigated how the emotional valence of pictures, which was stochastically contingent on participants’ choices, influenced subsequent decision making. In contrast to traditional value-based decision-making studies that used money or food as a reward...
Cooper, R.J.; Bissell, P.; Wingfield, J.
Background: Increasing interest in empirical ethics has enhanced understanding of healthcare professionals' ethical problems and attendant decision-making. A four-stage decision-making model involving ethical attention, reasoning, intention and action offers further insights into how more than reasoning alone may contribute to decision-making.\\ud \\ud Aims: To explore how the four-stage model can increase understanding of decision-making in healthcare and describe the decision-making of an und...
van der Veeken, Frida C A; Lucieer, Jacques; Bogaerts, Stefan
Rehabilitation in forensic psychiatry is achieved gradually with different leave modules, in line with the Risk Need Responsivity model. A forensic routine outcome monitoring tool should measure treatment progress based on the rehabilitation theory, and it should be predictive of important treatment outcomes in order to be usable in decision-making. Therefore, this study assesses the predictive validity for both positive (i.e., leave) and negative (i.e., inpatient incidents) treatment outcomes with the Instrument for Forensic Treatment Evaluation (IFTE). Two-hundred and twenty-four patients were included in this study. ROC analyses were conducted with the IFTE factors and items for three leave modules: guided, unguided and transmural leave for the whole group of patients. Predictive validity of the IFTE for aggression in general, physical aggression specifically, and urine drug screening (UDS) violations was assessed for patients with the main diagnoses in Dutch forensic psychiatry, patients with personality disorders and the most frequently occurring co-morbid disorders: those with combined personality and substance use disorders. Results tentatively imply that the IFTE has a reasonable to good predictive validity for inpatient aggression and a marginal to reasonable predictive value for leave approvals and UDS violations. The IFTE can be used for information purposes in treatment decision-making, but reports should be interpreted with care and acknowledge patients' personal risk factors, strengths and other information sources.
Esik, O; Seitz, W; Lövey, J; Knocke, T H; Gaudi, I; Németh, G; Pötter, R
To present an example of how to study and analyze the clinical practice and the quality of medical decision-making under daily routine working conditions in a radiotherapy department, with the aims of detecting deficiencies and improving the quality of patient care. Two departments, each with a divisional organization structure and an established internal audit system, the University Clinic of Radiotherapy and Radiobiology in Vienna (Austria), and the Department of Radiotherapy at the National Institute of Oncology in Budapest (Hungary), conducted common external audits. The descriptive parameters of the external audit provided information on the auditing (auditor and serial number of the audit), the cohorts (diagnosis, referring institution, serial number and intention of radiotherapy) and the staff responsible for the treatment (division and physician). During the ongoing external audits, the qualifying parameters were (1) the sound foundation of the indication of radiotherapy, (2) conformity to the institution protocol (3), the adequacy of the choice of radiation equipment, (4) the appropriateness of the treatment plan, and the correspondence of the latter with (5) the simulation and (6) verification films. Various degrees of deviation from the treatment principles were defined and scored on the basis of the concept of Horiot et al. (Horiot JC, Schueren van der E. Johansson KA, Bernier J, Bartelink H. The program of quality assurance of the EORTC radiotherapy group. A historical overview. Radiother. Oncol. 1993,29:81-84), with some modifications. The action was regarded as adequate (score 1) in the event of no deviation or only a small deviation with presumably no alteration of the desired end-result of the treatment. A deviation adversely influencing the result of the therapy was considered a major deviation (score 3). Cases involving a minor deviation (score 2) were those only slightly affecting the therapeutic end-results, with effects between those of cases
Esik, O.; Seitz, W.; Loevey, J.; Knocke, T.H.; Gaudi, I.; Nemeth, G.; Poetter, R.
Purpose: To present an example of how to study and analyze the clinical practice and the quality of medical decision-making under daily routine working conditions in a radiotherapy department, with the aims of detecting deficiencies and improving the quality of patient care.Methods: Two departments, each with a divisional organization structure and an established internal audit system, the University Clinic of Radiotherapy and Radiobiology in Vienna (Austria), and the Department of Radiotherapy at the National Institute of Oncology in Budapest (Hungary), conducted common external audits. The descriptive parameters of the external audit provided information on the auditing (auditor and serial number of the audit), the cohorts (diagnosis, referring institution, serial number and intention of radiotherapy) and the staff responsible for the treatment (division and physician). During the ongoing external audits, the qualifying parameters were (1) the sound foundation of the indication of radiotherapy, (2) conformity to the institution protocol (3), the adequacy of the choice of radiation equipment, (4) the appropriateness of the treatment plan, and the correspondence of the latter with (5) the simulation and (6) verification films. Various degrees of deviation from the treatment principles were defined and scored on the basis of the concept of Horiot et al. (Horiot JC, Schueren van der E, Johansson KA, Bernier J, Bartelink H. The program of quality assurance of the EORTC radiotherapy group. A historical overview. Radiother. Oncol. 1993;29:81-84), with some modifications. The action was regarded as adequate (score 1) in the event of no deviation or only a small deviation with presumably no alteration of the desired end-result of the treatment. A deviation adversely influencing the result of the therapy was considered a major deviation (score 3). Cases involving a minor deviation (score 2) were those only slightly affecting the therapeutic end-results, with effects
Full Text Available This paper compares a number of theoretical models of decision-making with the way in which senior managers make decisions in practice. Six prominent decision-makers were interviewed about their own decision-making style, as well as their use of decision support technology. Significant variation was found in personal decision-making styles. However, some central themes emerged, such as the importance of sensitivity to the decision-making context, attention to the presentation of information, and the use of intuition. In terms of the use of decision support technology, the use of self-help tools, such as office software, was clearly favoured.
Kidd Michael R
Full Text Available Abstract Background Online information retrieval systems have the potential to improve patient care but there are few comparative studies of the impact of online evidence on clinicians' decision-making behaviour in routine clinical work. Methods/design A randomized controlled parallel design is employed to assess the effectiveness of an online evidence retrieval system, Quick Clinical (QC in improving clinical decision-making processes in general practice. Eligible clinicians are randomised either to receive access or not to receive access to QC in their consulting rooms for 12 months. Participants complete pre- and post trial surveys. Two-hundred general practitioners are recruited. Participants must be registered to practice in Australia, have a computer with Internet access in their consulting room and use electronic prescribing. Clinicians planning to retire or move to another practice within 12 months or participating in any other clinical trial involving electronic extraction of prescriptions data are excluded from the study. The primary end-points for the study is clinician acceptance and use of QC and the resulting change in decision-making behaviour. The study will examine prescribing patterns related to frequently prescribed medications where there has been a recent significant shift in recommendations regarding their use based upon new evidence. Secondary outcome measures include self-reported changes in diagnosis, patient education, prescriptions written, investigations and referrals. Discussion A trial under experimental conditions is an effective way of examining the impact of using QC in routine general practice consultations.
Full Text Available Background: The decision about whether to start a family within a partnership can be viewed as a result of an interaction process. The influence of each of the partners in a couple differs depending on their individual preferences and intentions towards having children. Both of the partners additionally influence each other's fertility intentions and preferences. Objective: We specify, estimate, and test a model that examines the decision about whether to have a child as a choice that is made jointly by the two partners. The transition to the birth of a (further child is investigated with the explicit consideration of both the female partner and the male partner in the partnership context. Methods: An approach for modelling the interactive influences of the two actors in the decision-making process was proposed. A trivariate distribution consisting of both the female and the male partners' fertility intentions, as well as the joint generative decision, was modelled. A multivariate non-linear probit model was chosen and the problem of identification in estimating the relative effects of the actors was resolved. These parameters were used to assess the relative importance of each of the partners' intentions in the decision. We carried out the analysis with MPLUS. Data from the panel of intimate relationships and family dynamics (pairfam was used to estimate the model. Results: The biographical context of each of the partners in relation to their own as well as to their partner's fertility intentions was found to be of considerable importance. Of the significant individual and partner effects, the male partner was shown to have the greater influence. But the female partner was found to have stronger parameters overall and she ultimately has a veto power in the couple's final decision.
Lidegaard, O; Bøttcher, L M; Weber, Tom
departments, especially between departments far apart. It is concluded that we still need a scientific clarification of which specific heart rate changes are the best predictors of fetal stress. Artificial intelligence programs for interpreting fetal cardiotocograms and ECG signals constitute one promising......At 10 Danish obstetrical departments, 116 residents (42 senior and 74 junior) participated in a study to assess inter-observer and regional variability in the description and evaluation of and clinical decision regarding 11 fetal heart rate patterns. The 11 traces included normal as well...... as pathological patterns, and normal as well as clinically asphyxiated babies. Five antepartum and six intrapartum patterns were included. A total of 1,276 descriptions and evaluations were obtained. The degree of agreement in description of fetal heart rate changes was high regarding the baseline...
Slack, Stephanie M; Boguslawski, Jean M; Eickhoff, Rachel M; Klein, Kristi A; Pepin, Teresa M; Schrandt, Kevin; Wise, Carrie A; Zylstra, Jody A
Shared decision making is a process that has empowered specialty nurses at the Mayo Clinic in Rochester, MN, to solve a practice concern. Staff nurses recognized a lack of concise, collated information available that described what nurses need to know when caring for patients receiving chemotherapy. Many aspects of the administration process were knowledge and experience based and not easily retrievable. The Hematology/Oncology/Blood and Marrow Transplant Clinical Practice Committee identified this as a significant practice issue. Ideas were brainstormed regarding how to make the information available to nursing colleagues. The Chemotherapy Yellow Pages is a resource that was developed to facilitate the rapid retrieval of pertinent information for bedside nurses. The content of this article outlines a'model of shared decision making and the processes used to address and resolve the practice concern.
Hoag, Dana L.; Ascough, James C.; Keske-Handley, C.; Koontz, Lynne; Burk, A.R.
Since Ott's seminal book on environmental indices (1978), the use of indices has expanded into several natural resource disciplines, including ecological studies, environmental policymaking, and agricultural economics. However, despite their increasing use in natural resource disciplines, researchers and public decision makers continue to express concern about validity of these instruments to capture and communicate multidimensional, and sometimes disparate, characteristics of research data and stakeholder interests. Our purpose is to demonstrate how useful indices can be for communicating environmental information to decision makers. We discuss how environmental indices have evolved over four stages: 1) simple; 2) compound multicriteria; 3) the impact matrix and 4) disparate stakeholder management. We provide examples of simple and compound indices that were used by policy decision makers. We then build a framework, called an Impact Matrix (IM), that comprehensively accounts for multiple indices but lets the user decide how to integrate them. The IM was shaped from the concept of a financial risk payoff matrix and applied to ecosystem risk. While the IM offers flexibility, it does not address stakeholder preferences about which index to use. Therefore, the last phase in our evolutionary ladder includes stakeholder indices to specifically address disparate stakeholder preferences. Finally, we assert that an environmental index has the potential to increase resource efficiency, since the number of decision making resources may be reduced, and hence improve upon resource productivity
Kaiser, Katharina; Martini, Patrick; Miksch, Silvia; Öztürk, Alime
Clinical practice guidelines are an important instrument to aid physicians during medical diagnosis and treatment. Currently, different guideline developing organizations try to define and integrate evidence information into such guidelines. However, the coding schemas and taxonomies used for the evidence information differ widely, which makes the use cumbersome and demanding. We explored these various schemas and developed a meta schema for the evidence information, which covers the most imp...
Distributed Decision Making and Control is a mathematical treatment of relevant problems in distributed control, decision and multiagent systems, The research reported was prompted by the recent rapid development in large-scale networked and embedded systems and communications. One of the main reasons for the growing complexity in such systems is the dynamics introduced by computation and communication delays. Reliability, predictability, and efficient utilization of processing power and network resources are central issues and the new theory and design methods presented here are needed to analyze and optimize the complex interactions that arise between controllers, plants and networks. The text also helps to meet requirements arising from industrial practice for a more systematic approach to the design of distributed control structures and corresponding information interfaces Theory for coordination of many different control units is closely related to economics and game theory network uses being dictated by...
Montyla, Timo; Still, Johanna; Gullberg, Stina; Del Missier, Fabio
Objectives: This study examined decision-making competence in ADHD by using multiple decision tasks with varying demands on analytic versus affective processes. Methods: Adults with ADHD and healthy controls completed two tasks of analytic decision making, as measured by the Adult Decision-Making Competence (A-DMC) battery, and two affective…
This paper assesses the decision making patterns in medical ethics: the formalized pattern of decision science, the meditative pattern of an art of judgement and lastly the still-to-be-elaborated pattern of kairology or sense of the right time. The ethical decision is to be thought out in the conditions of medical action while resorting to the philosophical concepts that shed light on the issue. And it is precisely where medicine and philosophy of human action meet that the Greek notion of kairos, or "propitious moment", evokes the critical point where decision has to do with what is vital. Reflection shows that this kairos can be thought out outside the sacrificial pattern (deciding comes down to killing a possibility) by understanding the opportune moment as a sign of ethical action, as the condition for the formation of the subject (making a decision) and finally as a new relationship to time, including in the context of medical urgency. Thus with an approach to clinical ethics centred on the relation to the individual, the focus is less on the probabilistic knowledge of the decidable than on the meaning of the decision, and the undecidable comes to be accepted as an infinite dimension going beyond the limits of our acts, which makes the contingency and the grandeur of human responsibility.
Adida, M; Maurel, M; Kaladjian, A; Fakra, E; Lazerges, P; Da Fonseca, D; Belzeaux, R; Cermolacce, M; Azorin, J-M
Abnormalities involving the prefrontal cortex (PFC) have long been postulated to underpin the pathophysiology of schizophrenia. Investigations of PFC integrity have focused mainly on the dorsolateral PFC (DLPFC) and abnormalities in this region have been extensively documented. However, defects in schizophrenia may extend to other prefrontal regions, including the ventromedial PFC (VMPFC), and evidence of VMPFC abnormalities comes from neuropathological, structural and functional studies. Patients with acquired brain injury to the VMPFC display profound disruption of social behaviour and poor judgment in their personal lives. The Iowa Gambling Task (IGT) was developed to assess decision-making in these neurological cases : it presents a series of 100 choices from four card decks that differ in the distribution of rewarding and punishing outcomes. Whilst healthy volunteers gradually develop a preference for the two "safe" decks over the course of the task, patients with VMPFC lesions maintain a preference for the two "risky" decks which are associated with high reinforcement in the short term, but significant long-term debt. Interestingly, damage to VMPFC may cause both poor performance on the IGT and lack of insight concerning the acquired personality modification. Recently, our group reported a trait-related decisionmaking impairment in the three phases of bipolar disorder. In a PET study, VMPFC dysfunction was shown in bipolar manic patients impaired on a decision-making task and an association between decision-making cognition and lack of insight was described in mania. A quantitative association between grey matter volume of VMPFC and memory impairment was previously reported in schizophrenia. Research suggests that lack of insight is a prevalent feature in schizophrenia patients, like auditory hallucinations, paranoid or bizarre delusions, and disorganized speech and thinking. Because schizophrenia is associated with significant social or occupational
Forsythe, J Chris [Sandia Park, NM; Speed, Ann E [Albuquerque, NM; Jordan, Sabina E [Albuquerque, NM; Xavier, Patrick G [Albuquerque, NM
A method for computer emulation of human decision making defines a plurality of concepts related to a domain and a plurality of situations related to the domain, where each situation is a combination of at least two of the concepts. Each concept and situation is represented in the computer as an oscillator output, and each situation and concept oscillator output is distinguishable from all other oscillator outputs. Information is input to the computer representative of detected concepts, and the computer compares the detected concepts with the stored situations to determine if a situation has occurred.
Motlagh, Ali; Yaraei, Neda; Mafi, Ahmad R; Hosseini Kamal, Farnaz; Yaseri, Mehdi; Hemati, Simin; Shahbazian, Hojatollah; Sedighi, Abdol-Azim; Khodabakhshi, Reza; Taghizadeh, Ali; Ansari, Jamshid; Seyednejad, Farshad; Khanduzi, Reza; Mojir Sheibani, Khosro; Azadeh, Payam; Emranpour, Mohamad Hasan; Mosalei, Ahmad; Vojdani, Soheil; Nazari, Ali Mohamad; Nazarimenesh, Leila; Fazl-Alizadeh, Abdolah; Akbari, Mohamad Esmaeil
There is still contradictory evidence on disclosure preferences regarding cancer diagnosis. The aim of this study was to evaluate the preference of cancer patients for knowing the truth about their disease, as well as the factors that might have an impact on these preferences. This study was conducted in 11 cancer centers in Iran. A questionnaire was used to collect data, and all patients above 15 years of age who were willing to participate were included in the study. The patients were asked if they were aware of the malignant nature of their disease, and if they came to know about their disease at the time of initial diagnosis, or later. The patients were then asked about the way they looked upon their disease. In the final part of the questionnaire, the participants were asked the level of involvement they prefer to have in making treatment decisions. In total, 1226 patients were enrolled in this study, only 565 (46.7%) of whom were aware of their disease at the time of diagnosis, and 878 (72.7%) at the time of interview, while 980 (85.2%) were willing to receive information about their disease. Patients' awareness was significantly associated with age under 50 years, female gender, having breast, skin or head and neck cancer, and having medical care in Shiraz or Hamadan while it was not associated with the stage or accompanying illness. While the majority of Iranian cancer patients prefer to be aware of the nature of their disease and have an active role in treatment decision making, they do not receive this information.
Richter Sundberg, Linda; Garvare, Rickard; Nyström, Monica Elisabeth
The judgment and decision making process during guideline development is central for producing high-quality clinical practice guidelines, but the topic is relatively underexplored in the guideline research literature. We have studied the development process of national guidelines with a disease-prevention scope produced by the National board of Health and Welfare (NBHW) in Sweden. The NBHW formal guideline development model states that guideline recommendations should be based on five decision-criteria: research evidence; curative/preventive effect size, severity of the condition; cost-effectiveness; and ethical considerations. A group of health profession representatives (i.e. a prioritization group) was assigned the task of ranking condition-intervention pairs for guideline recommendations, taking into consideration the multiple decision criteria. The aim of this study was to investigate the decision making process during the two-year development of national guidelines for methods of preventing disease. A qualitative inductive longitudinal case study approach was used to investigate the decision making process. Questionnaires, non-participant observations of nine two-day group meetings, and documents provided data for the analysis. Conventional and summative qualitative content analysis was used to analyse data. The guideline development model was modified ad-hoc as the group encountered three main types of dilemmas: high quality evidence vs. low adoptability of recommendation; insufficient evidence vs. high urgency to act; and incoherence in assessment and prioritization within and between four different lifestyle areas. The formal guideline development model guided the decision-criteria used, but three new or revised criteria were added by the group: 'clinical knowledge and experience', 'potential guideline consequences' and 'needs of vulnerable groups'. The frequency of the use of various criteria in discussions varied over time. Gender, professional status
With the dissemination of non-invasive human neuroimaging techniques such as fMRI and the advancement of cognitive science, neuroimaging studies focusing on emotions and social cognition have become established. Along with this advancement, behavioral economics taking emotional and social factors into account for economic decisions has been merged with neuroscientific studies, and this interdisciplinary approach is called neuroeconomics. Past neuroeconomics studies have demonstrated that subcortical emotion-related brain structures play an important role in "irrational" decision-making. The research field that investigates the role of central neurotransmitters in this process is worthy of further development. Here, we provide an overview of recent molecular neuroimaging studies to further the understanding of the neurochemical basis of "irrational" or emotional decision-making and the future direction, including clinical implications, of the field. Copyright © 2013 Elsevier Ireland Ltd and the Japan Neuroscience Society. All rights reserved.
Bayesian evidence ratios give a very attractive way of comparing models, and being able to quote the odds on a particular model seems a very clear motivation for making a choice. Jeffreys' scale of evidence is often used in the interpretation of evidence ratios. A natural question is, how often will you get it right when you choose on the basis of some threshold value of the evidence ratio? The evidence ratio will be different in different realizations of the data, and its utility can be examined in a Neyman-Pearson like way to see what the trade-offs are between statistical power (the chance of "getting it right") versus the false alarm rate, picking the alternative hypothesis when the null is actually true. I will show some simple examples which show that there can be a surprisingly large range for an evidence ratio under different realizations of the data. It seems best not to simply rely on Jeffrey's scale when decisions have to be taken, but also to examine the probability of taking the "wrong" decision if some evidence ratio is taken to be decisive. Interestingly, Turing knew this and applied it during WWII, although (like much else) he did not publish it.
Bock, Gregory L
Patients can be harmed by a religiously motivated surrogate decision maker whose decisions are contrary to the standard of care; therefore, surrogate decision making should be held to a high standard. Stewart Eskew and Christopher Meyers proposed a two-part rule for deciding which religiously based decisions to honor: (1) a secular reason condition and (2) a rationality condition. The second condition is based on a coherence theory of rationality, which they claim is accessible, generous, and culturally sensitive. In this article, I will propose strengthening the rationality condition by grounding it in a theory of intellectual virtue, which is both rigorous and culturally sensitive. Copyright 2014 The Journal of Clinical Ethics. All rights reserved.
Kaiser, Katharina; Martini, Patrick; Miksch, Silvia; Oztürk, Alime
Clinical practice guidelines are an important instrument to aid physicians during medical diagnosis and treatment. Currently, different guideline developing organizations try to define and integrate evidence information into such guidelines. However, the coding schemas and taxonomies used for the evidence information differ widely, which makes the use cumbersome and demanding. We explored these various schemas and developed a meta schema for the evidence information, which covers the most important components of the existing ones, is comprehensible, and easy to understand for the users. We developed and assessed the usefulness and applicability of our meta schema with guideline developers and physicians.
Morrison, Jeffrey G.; Kelly, Richard T.; Moore, Ronald A.; Hutchins, Susan G.
A prototype decision support system (DSS) was developed to enhance Navy tactical decision making based on naturalistic decision processes. Displays were developed to support critical decision making tasks through recognition-primed and explanation-based reasoning processes and cognitive analysis of the decision making problems faced by Navy tactical officers in a shipboard Combat Information Center. Baseline testing in high intensity, peace keeping, littoral scenarios indicated...
Chen, Nien-Hsin; Lin, Yu-Ping; Liang, Shu-Yuan; Tung, Heng-Hsin; Tsay, Shiow-Luan; Wang, Tsae-Jyy
To explore decisional conflict and its influencing factors on choosing dialysis modality in patients with end-stage renal diseases. The influencing factors investigated include demographics, predialysis education, dialysis knowledge, decision self-efficacy and social support. Making dialysis modality decisions can be challenging for patients with end-stage renal diseases; there are pros and cons to both haemodialysis and peritoneal dialysis. Patients are often uncertain as to which one will be the best alternative for them. This decisional conflict increases the likelihood of making a decision that is not based on the patient's values or preferences and may result in undesirable postdecisional consequences. Addressing factors predisposing patients to decisional conflict helps to facilitate informed decision-making and then to improve healthcare quality. A predictive correlational cross-sectional study design was used. Seventy patients were recruited from the outpatient dialysis clinics of two general hospitals in Taiwan. Data were collected with study questionnaires, including questions on demographics, dialysis modality and predialysis education, the Dialysis Knowledge Scale, the Decision Self-Efficacy scale, the Social Support Scale, and the Decisional Conflict Scale. The mean score on the Decisional Conflict Scale was 29.26 (SD = 22.18). Decision self-efficacy, dialysis modality, predialysis education, professional support and dialysis knowledge together explained 76.4% of the variance in decisional conflict. Individuals who had lower decision self-efficacy, did not receive predialysis education on both haemodialysis and peritoneal dialysis, had lower dialysis knowledge and perceived lower professional support reported higher decisional conflict on choosing dialysis modality. When providing decisional support to predialysis stage patients, practitioners need to increase patients' decision self-efficacy, provide both haemodialysis and peritoneal dialysis
Hauer, Karen E; Cate, Olle Ten; Boscardin, Christy K; Iobst, William; Holmboe, Eric S; Chesluk, Benjamin; Baron, Robert B; O'Sullivan, Patricia S
Background The expectation for graduate medical education programs to ensure that trainees are progressing toward competence for unsupervised practice prompted requirements for a committee to make decisions regarding residents' progress, termed a clinical competency committee (CCC). The literature on the composition of these committees and how they share information and render decisions can inform the work of CCCs by highlighting vulnerabilities and best practices. Objective We conducted a narrative review of the literature on group decision making that can help characterize the work of CCCs, including how they are populated and how they use information. Methods English language studies of group decision making in medical education, psychology, and organizational behavior were used. Results The results highlighted 2 major themes. Group member composition showcased the value placed on the complementarity of members' experience and lessons they had learned about performance review through their teaching and committee work. Group processes revealed strengths and limitations in groups' understanding of their work, leader role, and information-sharing procedures. Time pressure was a threat to the quality of group work. Conclusions Implications of the findings include the risks for committees that arise with homogeneous membership, limitations to available resident performance information, and processes that arise through experience rather than deriving from a well-articulated purpose of their work. Recommendations are presented to maximize the effectiveness of CCC processes, including their membership and access to, and interpretation of, information to yield evidence-based, well-reasoned judgments.
Henshall, Catherine; Marzano, Lisa; Smith, Katharine; Attenburrow, Mary-Jane; Puntis, Stephen; Zlodre, Jakov; Kelly, Kathleen; Broome, Matthew R; Shaw, Susan; Barrera, Alvaro; Molodynski, Andrew; Reid, Alastair; Geddes, John R; Cipriani, Andrea
Treatment decision tools have been developed in many fields of medicine, including psychiatry, however benefits for patients have not been sustained once the support is withdrawn. We have developed a web-based computerised clinical decision support tool (CDST), which can provide patients and clinicians with continuous, up-to-date, personalised information about the efficacy and tolerability of competing interventions. To test the feasibility and acceptability of the CDST we conducted a focus group study, aimed to explore the views of clinicians, patients and carers. The CDST was developed in Oxford. To tailor treatments at an individual level, the CDST combines the best available evidence from the scientific literature with patient preferences and values, and with patient medical profile to generate personalised clinical recommendations. We conducted three focus groups comprising of three different participant types: consultant psychiatrists, participants with a mental health diagnosis and/or experience of caring for someone with a mental health diagnosis, and primary care practitioners and nurses. Each 1-h focus group started with a short visual demonstration of the CDST. To standardise the discussion during the focus groups, we used the same topic guide that covered themes relating to the acceptability and usability of the CDST. Focus groups were recorded and any identifying participant details were anonymised. Data were analysed thematically and managed using the Framework method and the constant comparative method. The focus groups took place in Oxford between October 2016 and January 2017. Overall 31 participants attended (12 consultants, 11 primary care practitioners and 8 patients or carers). The main themes that emerged related to CDST applications in clinical practice, communication, conflicting priorities, record keeping and data management. CDST was considered a useful clinical decision support, with recognised value in promoting clinician
Tunney, Richard J; Ziegler, Fenja V
In everyday life, many of the decisions that we make are made on behalf of other people. A growing body of research suggests that we often, but not always, make different decisions on behalf of other people than the other person would choose. This is problematic in the practical case of legally designated surrogate decision makers, who may not meet the substituted judgment standard. Here, we review evidence from studies of surrogate decision making and examine the extent to which surrogate decision making accurately predicts the recipient's wishes, or if it is an incomplete or distorted application of the surrogate's own decision-making processes. We find no existing domain-general model of surrogate decision making. We propose a framework by which surrogate decision making can be assessed and a novel domain-general theory as a unifying explanatory concept for surrogate decisions. © The Author(s) 2015.
Beam, Andrew L.; Kartoun, Uri; Pai, Jennifer K.; Chatterjee, Arnaub K.; Fitzgerald, Timothy P.; Shaw, Stanley Y.; Kohane, Isaac S.
Insomnia remains under-diagnosed and poorly treated despite its high economic and social costs. Though previous work has examined how patient characteristics affect sleep medication prescriptions, the role of physician characteristics that influence this clinical decision remains unclear. We sought to understand patient and physician factors that influence sleep medication prescribing patterns by analyzing Electronic Medical Records (EMRs) including the narrative clinical notes as well as codified data. Zolpidem and trazodone were the most widely prescribed initial sleep medication in a cohort of 1,105 patients. Some providers showed a historical preference for one medication, which was highly predictive of their future prescribing behavior. Using a predictive model (AUC = 0.77), physician preference largely determined which medication a patient received (OR = 3.13 p = 3 × 10-37). In addition to the dominant effect of empirically determined physician preference, discussion of depression in a patient’s note was found to have a statistically significant association with receiving a prescription for trazodone (OR = 1.38, p = 0.04). EMR data can yield insights into physician prescribing behavior based on real-world physician-patient interactions.
Scholes, Julie; Endacott, Ruth; Biro, MaryAnne; Bulle, Bree; Cooper, Simon; Miles, Maureen; Gilmour, Carole; Buykx, Penny; Kinsman, Leigh; Boland, Rosemarie; Jones, Jan; Zaidi, Fawzia
This paper reports the findings of a study of how midwifery students responded to a simulated post partum haemorrhage (PPH). Internationally, 25% of maternal deaths are attributed to severe haemorrhage. Although this figure is far higher in developing countries, the risk to maternal wellbeing and child health problem means that all midwives need to remain vigilant and respond appropriately to early signs of maternal deterioration. Simulation using a patient actress enabled the research team to investigate the way in which 35 midwifery students made decisions in a dynamic high fidelity PPH scenario. The actress wore a birthing suit that simulated blood loss and a flaccid uterus on palpation. The scenario provided low levels of uncertainty and high levels of relevant information. The student's response to the scenario was videoed. Immediately after, they were invited to review the video, reflect on their performance and give a commentary as to what affected their decisions. The data were analysed using Dimensional Analysis. The students' clinical management of the situation varied considerably. Students struggled to prioritize their actions where more than one response was required to a clinical cue and did not necessarily use mnemonics as heuristic devices to guide their actions. Driven by a response to single cues they also showed a reluctance to formulate a diagnosis based on inductive and deductive reasoning cycles. This meant they did not necessarily introduce new hypothetical ideas against which they might refute or confirm a diagnosis and thereby eliminate fixation error. The students response demonstrated that a number of clinical skills require updating on a regular basis including: fundal massage technique, the use of emergency standing order drugs, communication and delegation of tasks to others in an emergency and working independently until help arrives. Heuristic devices helped the students to evaluate their interventions to illuminate what else could
Full Text Available Abstract Background This paper reports the findings of a study of how midwifery students responded to a simulated post partum haemorrhage (PPH. Internationally, 25% of maternal deaths are attributed to severe haemorrhage. Although this figure is far higher in developing countries, the risk to maternal wellbeing and child health problem means that all midwives need to remain vigilant and respond appropriately to early signs of maternal deterioration. Methods Simulation using a patient actress enabled the research team to investigate the way in which 35 midwifery students made decisions in a dynamic high fidelity PPH scenario. The actress wore a birthing suit that simulated blood loss and a flaccid uterus on palpation. The scenario provided low levels of uncertainty and high levels of relevant information. The student's response to the scenario was videoed. Immediately after, they were invited to review the video, reflect on their performance and give a commentary as to what affected their decisions. The data were analysed using Dimensional Analysis. Results The students' clinical management of the situation varied considerably. Students struggled to prioritise their actions where more than one response was required to a clinical cue and did not necessarily use mnemonics as heuristic devices to guide their actions. Driven by a response to single cues they also showed a reluctance to formulate a diagnosis based on inductive and deductive reasoning cycles. This meant they did not necessarily introduce new hypothetical ideas against which they might refute or confirm a diagnosis and thereby eliminate fixation error. Conclusions The students response demonstrated that a number of clinical skills require updating on a regular basis including: fundal massage technique, the use of emergency standing order drugs, communication and delegation of tasks to others in an emergency and working independently until help arrives. Heuristic devices helped the
Li Hao; Wing Suen
This article reviews recent developments in the theory of committee decision-making. A committee consists of self-interested members who make a public decision by aggregating imperfect information dispersed among them according to a pre-specified decision rule. We focus on costly information acquisition, strategic information aggregation, and rules and processes that enhance the quality of the committee decision. Seeming inefficiencies of the committee decision-making process such as over-cau...
Wolgast, Kelly A
Decision-making is the mainstay of military leadership and command. Due to the changed nature of the current military environment, military commanders can no longer rely solely on the traditional Military Decision-making Process (MDMP...
Harber, Jean R.
The utility of the procedures special educators apply in making decisions about the identification of handicapped individuals has not been thoroughly studied. The paper examines the utility of diagnostic decision making from the perspective of receiver operating curve analysis. (Author)
Phillips, Patrick P J; Mendel, Carl M; Burger, Divan A; Crook, Angela M; Crook, Angela; Nunn, Andrew J; Dawson, Rodney; Diacon, Andreas H; Gillespie, Stephen H
Despite recent increased clinical trials activity, no regimen has proved able to replace the standard 6-month regimen for drug-sensitive tuberculosis. Understanding the relationship between microbiological markers measured during treatment and long-term clinical outcomes is critical to evaluate their usefulness for decision-making for both individual patient care and for advancing novel regimens into time-consuming and expensive pivotal phase III trials. Using data from the randomized controlled phase III trial REMoxTB, we evaluated sputum-based markers of speed of clearance of bacilli: time to smear negative status; time to culture negative status on LJ or in MGIT; daily rate of change of log10(TTP) to day 56; and smear or culture results at weeks 6, 8 or 12; as individual- and trial-level surrogate endpoints for long-term clinical outcome. Time to culture negative status on LJ or in MGIT, time to smear negative status and daily rate of change in log10(TTP) were each independent predictors of clinical outcome, adjusted for treatment (p limited role in decision-making for advancing regimens into phase III trials or in predicting the outcome of treatment for individual patients. REMoxTB ClinicalTrials.gov number: NCT00864383.
Sundaresan, Puma; Ager, Brittany; Turner, Sandra; Costa, Dan; Kneebone, Andrew; Pearse, Maria; Woo, Henry; Tesson, Stephanie; Juraskova, Ilona; Butow, Phyllis
Randomised controlled trials (RCTs) are considered the 'gold-standard' for evaluating medical treatments. However, patients and clinicians report difficulties with informed consent and recruitment. We evaluated the utility of a Decision Aid (DA) in reducing RCT-related decisional conflict, and improving RCT knowledge and recruitment. Potential participants for a radiotherapy RCT were invited to participate in the current study. Participants were randomised to receive the RCT's participant information sheet with or without a DA. Questionnaires were administered at baseline, one and six months. The primary outcome measure was decisional conflict. Secondary outcome measures included knowledge regarding and recruitment to the RCT. 129 men were randomised to the DA (63) and control (66) arms. Decisional conflict was significantly lower over 6-months (p=0.048) in the DA arm. Knowledge regarding the RCT was significantly higher at 6months (p=0.033) in the DA arm. 20.6% of the DA arm (13 of 63) and 9% of the control arm (6 of 66) entered the RCT. This study demonstrates the utility of a DA in reducing decisional conflict and improving trial knowledge in men with cancer who are making decisions regarding RCT participation. Crown Copyright © 2017. Published by Elsevier B.V. All rights reserved.
Anat Bracha; Donald J. Brown
Affective decision-making is a strategic model of choice under risk and uncertainty where we posit two cognitive processes -- the "rational" and the "emotional" process. Observed choice is the result of equilibrium in this intrapersonal game. As an example, we present applications of affective decision-making in insurance markets, where the risk perceptions of consumers are endogenous. We derive the axiomatic foundation of affective decision making, and show that affective decision making is ...
A rule-based decision making model is designed in G2 environment. A theoretical and methodological frame for the model is composed and motivated. The rule-based decision making model is based on object-oriented modelling, knowledge engineering and decision theory. The idea of safety objective tree is utilized. Advanced rule-based methodologies are applied. A general decision making model 'decision element' is constructed. The strategy planning of the decision element is based on e.g. value theory and utility theory. A hypothetical process model is built to give input data for the decision element. The basic principle of the object model in decision making is division in tasks. Probability models are used in characterizing component availabilities. Bayes' theorem is used to recalculate the probability figures when new information is got. The model includes simple learning features to save the solution path. A decision analytic interpretation is given to the decision making process. (author)
Students must make decisions about their lifestyle, future careers, academic pursuits, and classroom and school issues. Learning to make effective decisions for themselves and for society is an important aspect of competence. They can learn decision making through interacting and solving problems with others. A central ingredient for successful…
include factors such as personality, emotion , and level of expertise, which vary from individual to individual. The process of decision - making during... rational choice theories such as utility theory, to more descriptive psychological models that focus more on the process of decision - making ...descriptive nature, they provide a more realistic representation of human decision - making than the rationally based models. However these models do
Frantzidis, Christos A; Gilou, Sotiria; Billis, Antonis; Karagianni, Maria; Bratsas, Charalampos D; Bamidis, Panagiotis
Recent neuroscientific studies focused on the identification of pathological neurophysiological patterns (emotions, geriatric depression, memory impairment and sleep disturbances) through computerised clinical decision-support systems. Almost all these research attempts employed either resting-state condition (e.g. eyes-closed) or event-related potentials extracted during a cognitive task known to be affected by the disease under consideration. This Letter reviews existing data mining techniques and aims to enhance their robustness by proposing a holistic decision framework dealing with comorbidities and early symptoms' identification, while it could be applied in realistic occasions. Multivariate features are elicited and fused in order to be compared with average activities characteristic of each neuropathology group. A proposed model of the specific cognitive function which may be based on previous findings (a priori information) and/or validated by current experimental data should be then formed. So, the proposed scheme facilitates the early identification and prevention of neurodegenerative phenomena. Neurophysiological semantic annotation is hypothesised to enhance the importance of the proposed framework in facilitating the personalised healthcare of the information society and medical informatics research community.
Bandyopadhyay, Debarati; Pammi, V S Chandrasekhar; Srinivasan, Narayanan
Emotion plays a major role in influencing our everyday cognitive and behavioral functions, including decision making. We introduce different ways in which emotions are characterized in terms of the way they influence or elicited by decision making. This chapter discusses different theories that have been proposed to explain the role of emotions in judgment and decision making. We also discuss incidental emotional influences, both long-duration influences like mood and short-duration influences by emotional context present prior to or during decision making. We present and discuss results from a study with emotional pictures presented prior to decision making and how that influences both decision processes and postdecision experience as a function of uncertainty. We conclude with a summary of the work on emotions and decision making in the context of decision-making theories and our work on incidental emotions. Copyright © 2013 Elsevier B.V. All rights reserved.
Jaglal Susan B
Full Text Available Abstract Background Despite evidence of the benefits of research use in post-acute stroke rehabilitation where compliance with clinical practice guidelines has been associated with functional recovery and patient satisfaction, the rate of reliance on the research literature in clinical decision making among physical therapists is low. More research examining factors that motivate physical therapists to consider research findings in neurological practice is needed to inform efforts to intervene. The objective of this study was to identify practitioner, organizational, and research characteristics associated with research use among physical therapists providing services post-stroke. Methods A cross-sectional mail survey of physical therapists providing services to people with stroke in Ontario, Canada was conducted. The survey questionnaire contained items to evaluate practitioner and organizational characteristics and perceptions of research considered to influence evidence-based practice (EBP, as well as the frequency of using research evidence in clinical decision making in a typical month. Ordinal regression was used to identify factors associated with research use. Results The percentage of respondents reporting research use in clinical decision making 0 to 1, 2 to 5, or 6+ times in a typical month was 33.8%, 52.9%, and 13.3%, respectively (n = 263. Academic preparation in the principles of EBP, research participation, service as a clinical instructor, self-efficacy to implement EBP, a positive attitude towards research, perceived organizational support of research use, and Internet access to bibliographic databases at work were each associated with research use and placed in the final regression model. In the final model (n = 244, academic preparation in EBP, EBP self-efficacy, agreement that research findings are useful, and research participation each remained significantly associated with research use after adjusting for the effects of
Full Text Available This paper presents some characteristics and dilemmas of collective decision making. Collective decision making could be presented as the process of successive crystallization of dominant alternatives under the influence of different decision contexts from primary given decision potentials. This process is presented as the many-phased process of the acting of contextually dependent “energizing factors” of the collective decision making on the “attractiveness matrix” of outcomes of collective decisions. The attractiveness matrix determines the attractiveness for each alternative of decision, and the most attractive alternative in the given situation presents the rational decision in the given situation. In the final phase of decision making holds a context which gets a simplified attractiveness matrix. It corresponds to the common decision for one of the alternatives.
Weisman, C S; Plichta, S; Nathanson, C A; Chase, G A; Ensminger, M E; Robinson, J C
A modified rational decision model incorporating salient events and social influences (particularly from sexual partners) is used to analyze adolescent women's consistent use of oral contraceptives (OCs) over a six-month period. Data are taken from a panel study of 308 clients of an inner-city family planning clinic. Expected OC use was computed for each subject on the basis of subjective expected utility (SEU) theory, and is found in multivariate analyses to be a significant predictor of actual OC use. In addition, variables representing baseline and follow-up partner influences, the salience of pregnancy for the subject, and positive side effects of OCs during the first months of use are found to predict OC use. Partner's support of OC use during follow-up and positive side effects of OCs are found to predict OC use among subjects for whom OC use was not the expected decision according to baseline SEU. Implications of the findings for models of adolescents' contraceptive behavior and for clinicians are discussed.
Stroh, Mark; Addy, Carol; Wu, Yunhui; Stoch, S Aubrey; Pourkavoos, Nazaneen; Groff, Michelle; Xu, Yang; Wagner, John; Gottesdiener, Keith; Shadle, Craig; Wang, Hong; Manser, Kimberly; Winchell, Gregory A; Stone, Julie A
We describe how modeling and simulation guided program decisions following a randomized placebo-controlled single-rising oral dose first-in-man trial of compound A where an undesired transient blood pressure (BP) elevation occurred in fasted healthy young adult males. We proposed a lumped-parameter pharmacokinetic-pharmacodynamic (PK/PD) model that captured important aspects of the BP homeostasis mechanism. Four conceptual units characterized the feedback PD model: a sinusoidal BP set point, an effect compartment, a linear effect model, and a system response. To explore approaches for minimizing the BP increase, we coupled the PD model to a modified PK model to guide oral controlled-release (CR) development. The proposed PK/PD model captured the central tendency of the observed data. The simulated BP response obtained with theoretical release rate profiles suggested some amelioration of the peak BP response with CR. This triggered subsequent CR formulation development; we used actual dissolution data from these candidate CR formulations in the PK/PD model to confirm a potential benefit in the peak BP response. Though this paradigm has yet to be tested in the clinic, our model-based approach provided a common rational framework to more fully utilize the limited available information for advancing the program.
Forbes, Helen; Bucknall, Tracey K; Hutchinson, Alison M
Clinical decision-making is a complex activity that is critical to patient safety. Simulation, augmented by feedback, affords learners the opportunity to learn critical clinical decision-making skills. More detailed feedback following simulation exercises has the potential to further enhance student learning, particularly in relation to developing improved clinical decision-making skills. To investigate the feasibility of head-mounted video camera recordings, to augment feedback, following acute patient deterioration simulations. Pilot study using an observational design. Ten final-year nursing students participated in three simulation exercises, each focussed on detection and management of patient deterioration. Two observers collected behavioural data using an adapted version of Gaba's Clinical Simulation Tool, to provide verbal feedback to each participant, following each simulation exercise. Participants wore a head-mounted video camera during the second simulation exercise only. Video recordings were replayed to participants to augment feedback, following the second simulation exercise. Data were collected on: participant performance (observed and perceived); participant perceptions of feedback methods; and head-mounted video camera recording feasibility and capability for detailed audio-visual feedback. Management of patient deterioration improved for six participants (60%). Increased perceptions of confidence (70%) and competence (80%), were reported by the majority of participants. Few participants (20%) agreed that the video recording specifically enhanced their learning. The visual field of the head-mounted video camera was not always synchronised with the participant's field of vision, thus affecting the usefulness of some recordings. The usefulness of the video recordings, to enhance verbal feedback to participants on detection and management of simulated patient deterioration, was inconclusive. Modification of the video camera glasses, to improve
Schalkers, Inge; Enthoven, Clair; Bunders, Joske; Dedding, Christine
Children are not just small adults; they need to be diagnosed and treated in the context of their rapid growth and development. However, in guideline development, children's needs and interests are still overlooked. This study aims (1) to develop a tool that could stimulate guideline developers to take children into account on a more structural basis and (2) to explore how to facilitate children's participation in the process of guideline development. The method used was a three-phase multimethod sequential design. Professionals involved in guideline development participated in interviews (n = 12), filled in a questionnaire (n = 60) and/or participated in the focus group meeting (n = 11). This study results in a comprehensive understanding of the considerations that professionals take into account when deciding whether guidelines need to apply to children specifically. This resulted in a tool that assists guideline developers to make this assessment more accurately. It takes the form of a flowchart that guides users through a series of critical questions. The flowchart reminds guideline developers to consider children as a particular patient population when prioritizing and demarcating new guideline topics. It will help to ensure that clinical guidelines address children's unique health care needs and perspectives. Facilitating children's and parents' participation in the process of guideline development is perceived as challenging; nevertheless, it should be the next step in making paediatric guidelines more child-centred and family-centred. © 2016 John Wiley & Sons, Ltd.
Effective decision making under time constraints is often overlooked in medical decision making. The recognition primed decision making (RPDM) model was developed by Gary Klein based on previous recognized situations to develop a satisfactory solution to the current problem. Bayes Theorem is the most popular decision making model in medicine but is limited by the need for adequate time to consider all probabilities. Unlike other decision making models, there is a potential neurobiological basis for RPDM. This model has significant implication for health informatics and medical education.
Seidl, C.; Traub, S.
This paper investigates the existence of an editing phase and studies the com- pliance of subjects' behaviour with the most popular multiattribute decision rules. We observed that our data comply well with the existence of an editing phase, at least if we allow for a natural error rate of some 25%.
Full Text Available The levels of brain-derived neurotrophic factor (BDNF are significantly decreased in patients with schizophrenia and correlate with impairments in cognitive function. However, no study has investigated the relationship between the serum BDNF levels and decision-making. We compared patients with schizophrenia to healthy controls with respect to their decision-making ability and serum BDNF levels. Eighty-six chronic schizophrenia patients and 51 healthy controls participated in this study. We controlled for gender, age, and estimated intelligence quotient (IQ, and we investigated the differences in decision-making performance on the Iowa Gambling Task (IGT between the schizophrenia patient and control groups. We also compared the IGT scores, the serum BDNF levels, and the clinical symptoms between the groups. The IGT scores of the schizophrenia patients were lower than those of the controls. A negative correlation was detected between the mean net scores on the trials in the final two blocks and the serum BDNF levels（p<0.05）. Multiple regression analysis revealed that depressive symptoms and the serum BDNF levels were significantly associated with the mean net scores on the trials in the final two blocks. Based on these results, impaired sensitivity to both reward and punishment is associated with depressive symptoms and reduced serum BDNF levels in chronic schizophrenia patients and may be related to their poor performance on the IGT.
Alonso-Coello, Pablo; Oxman, Andrew D; Moberg, Jenny; Brignardello-Petersen, Romina; Akl, Elie A; Davoli, Marina; Treweek, Shaun; Mustafa, Reem A; Vandvik, Per O; Meerpohl, Joerg; Guyatt, Gordon H; Schünemann, Holger J
Clinicians do not have the time or resources to consider the underlying evidence for the myriad decisions they must make each day and, as a consequence, rely on recommendations from clinical practice guidelines. Guideline panels should consider all the relevant factors (criteria) that influence a decision or recommendation in a structured, explicit, and transparent way and provide clinicians with clear and actionable recommendations. In this article, we will describe the Evidence to Decision (EtD) frameworks for clinical practice recommendations. The general structure of the EtD framework for clinical recommendations is similar to EtD frameworks for other types of recommendations and decisions, and includes formulation of the question, an assessment of the different criteria, and conclusions. Clinical recommendations require considering criteria differently, depending on whether an individual patient or a population perspective is taken. For example, from an individual patient's perspective, out-of-pocket costs are an important consideration, whereas, from a population perspective, resource use (not only out-of-pocket costs) and cost effectiveness are important. From a population perspective, equity, acceptability, and feasibility are also important considerations, whereas the importance of these criteria is often limited from an individual patient perspective. Specific subgroups for which different recommendations may be required should be clearly identified and considered in relation to each criterion because judgments might vary across subgroups. This article is a translation of the original article published in the British Medical Journal. The EtD frameworks are currently used in the Clinical Practice Guideline Programme of the Spanish National Health System, co-ordinated by GuíaSalud. Copyright © 2017 SESPAS. Publicado por Elsevier España, S.L.U. All rights reserved.
Full Text Available BACKGROUND: Oral pre-exposure prophylaxis (PrEP can be clinically effective and cost-effective for HIV prevention in high-risk men who have sex with men (MSM. However, individual patients have different risk profiles, real-world populations vary, and no practical tools exist to guide clinical decisions or public health strategies. We introduce a practical model of HIV acquisition, including both a personalized risk calculator for clinical management and a cost-effectiveness calculator for population-level decisions. METHODS: We developed a decision-analytic model of PrEP for MSM. The primary clinical effectiveness and cost-effectiveness outcomes were the number needed to treat (NNT to prevent one HIV infection, and the cost per quality-adjusted life-year (QALY gained. We characterized patients according to risk factors including PrEP adherence, condom use, sexual frequency, background HIV prevalence and antiretroviral therapy use. RESULTS: With standard PrEP adherence and national epidemiologic parameters, the estimated NNT was 64 (95% uncertainty range: 26, 176 at a cost of $160,000 (cost saving, $740,000 per QALY--comparable to other published models. With high (35% HIV prevalence, the NNT was 35 (21, 57, and cost per QALY was $27,000 (cost saving, $160,000, and with high PrEP adherence, the NNT was 30 (14, 69, and cost per QALY was $3,000 (cost saving, $200,000. In contrast, for monogamous, serodiscordant relationships with partner antiretroviral therapy use, the NNT was 90 (39, 157 and cost per QALY was $280,000 ($14,000, $670,000. CONCLUSIONS: PrEP results vary widely across individuals and populations. Risk calculators may aid in patient education, clinical decision-making, and cost-effectiveness evaluation.
García-Altés, Anna; Argimon, Josep M
Improving the quality and transparency of governmental healthcare decision-making has an impact on the health of the population through policies, organisational management and clinical practice. Moreover, the comparison between healthcare centres and the transparent feedback of results to professionals and to the wider public contribute directly to improved results. The "Results Centre" of the Catalan healthcare system measures and disseminates the results achieved by the different healthcare centres in order to facilitate a shared decision-making process, thereby enhancing the quality of healthcare provided to the population of Catalonia (Spain). This is a pioneering initiative in Spain and is aligned with the most advanced countries in terms of policies of transparency and accountability. Copyright © 2016 SESPAS. Publicado por Elsevier España, S.L.U. All rights reserved.
Electroencephalogy ( EEG ) Feedback In Decision- Making The goal of this project is to investigate whether Electroencephalogy ( EEG ) can provide useful...feedback when training rapid decision-making. More specifically, EEG will allow us to provide online feedback about the neural decision processes...Electroencephalogy ( EEG ) Feedback In Decision-Making Report Title The goal of this project is to investigate whether Electroencephalogy ( EEG ) can provide useful
Full Text Available The main purpose of this study is to explore the relation between decision-making styles which are measured by the General decision-making style (GDMS test and information processing styles which are often termed cognitive styles and are, in this study, measured by Cognitive Style Inventory. The authors directed a survey research on 162 Iranian students. Structural equation modeling techniques were used to measure the impact of cognitive styles on decision-making styles. The authors found that cognitive styles have a positive impact on decision-making styles. In spite of the abundant research on factors that affect decision-making styles, few researches have tested the relationship between cognitive styles and decision-making styles. This study examines the impact of cognitive styles on decision-making styles in Iran. This study, like most research paper studies, cannot easily be generalized. Furthermore, the results of this study could be affected by economic conditions.
During the last thirty years different methods have been proposed in order to manage and resolve ethical quandaries, specially in the clinical setting. Some of these methodologies are based on the principles of Decision-making theory. Others looked to other philosophical traditions, like Principlism, Hermeneutics, Narrativism, Casuistry, Pragmatism, etc. This paper defends the view that deliberation is the cornerstone of any adequate methodology. This is due to the fact that moral decisions must take into account not only principles and ideas, but also emotions, values and beliefs. Deliberation is the process in which everyone concerned by the decision is considered a valid moral agent, obliged to give reasons for their own points of view, and to listen to the reasons of others. The goal of this process is not the reaching of a consensus but the enrichment of one's own point of view with that of the others, increasing in this way the maturity of one's own decision, in order to make it more wise or prudent. In many cases the members of a group of deliberation will differ in the final solution of the case, but the confrontation of their reasons will modify the perception of the problem of everyone. This is the profit of the process. Our moral decisions cannot be completely rational, due to the fact that they are influenced by feelings, values, beliefs, etc., but they must be reasonable, that is, wise and prudent. Deliberation is the main procedure to reach this goal. It obliges us to take others into account, respecting their different beliefs and values and prompting them to give reasons for their own points of view. This method has been traditional in Western clinical medicine all over its history, and it should be also the main procedure for clinical ethics.
Hermans, Caroline M.; Erickson, Jon D.; Erickson, Jon D.; Messner, Frank; Ring, Irene
Environmental decision making involving multiple stakeholders can benefit from the use of a formal process to structure stakeholder interactions, leading to more successful outcomes than traditional discursive decision processes. There are many tools available to handle complex decision making. Here we illustrate the use of a multicriteria decision analysis (MCDA) outranking tool (PROMETHEE) to facilitate decision making at the watershed scale, involving multiple stakeholders, multiple criteria, and multiple objectives. We compare various MCDA methods and their theoretical underpinnings, examining methods that most realistically model complex decision problems in ways that are understandable and transparent to stakeholders.
Hessinger, Jonathan D; London, Melissa J; Baer, Sheila M
The Veterans Health Administration (VHA) has continued to emphasize the availability, access, and utilization of high quality mental health care particularly in the treatment of posttraumatic stress disorder (PTSD). While dissemination and availability of evidence-based psychotherapies (EBPs) have only increased, treatment engagement and utilization have continued to be oft-noted challenges. Administrators, researchers, and individual clinicians have continued to develop and explore novel systemic and individualized interventions to address these issues. Pilot studies utilizing shared decision-making models to aid in veteran treatment selection have demonstrated the impact this approach may have on selection of and engagement in EBPs for PTSD. Based on these promising studies, a Department of Veterans Affairs (VA) outpatient PTSD clinic began to implement a shared-decision making intervention as part of a clinic redesign. In seeking to evaluate the impact of this intervention, archival clinical data from 1,056 veterans were reviewed by the authors for rates of treatment selection, EBP initiation, session attendance, and EBP completion. Time elapsed from consult until EBP initiation was also computed by the authors. These variables were then compared on the basis of whether the veteran received the shared-decision making intervention. Veterans who received the intervention were more likely to select and thus initiate an EBP for PTSD sooner than veterans who did not receive this intervention. Veterans, whether receiving the intervention or not, did not differ in therapy session attendance and completion. Implications of these findings and directions for future study are further discussed. (PsycINFO Database Record (c) 2017 APA, all rights reserved).
Goulet-Kennedy, Julie; Labbe, Sara; Fecteau, Shirley
Decision making has been extensively studied in the context of economics and from a group perspective, but still little is known on individual decision making. Here we discuss the different cognitive processes involved in decision making and its associated neural substrates. The putative conductors in decision making appear to be the prefrontal cortex and the striatum. Impaired decision-making skills in various clinical populations have been associated with activity in the prefrontal cortex and in the striatum. We highlight the importance of strengthening the degree of integration of both cognitive and neural substrates in order to further our understanding of decision-making skills. In terms of cognitive paradigms, there is a need to improve the ecological value of experimental tasks that assess decision making in various contexts and with rewards; this would help translate laboratory learnings into real-life benefits. In terms of neural substrates, the use of neuroimaging techniques helps characterize the neural networks associated with decision making; more recently, ways to modulate brain activity, such as in the prefrontal cortex and connected regions (eg, striatum), with noninvasive brain stimulation have also shed light on the neural and cognitive substrates of decision making. Together, these cognitive and neural approaches might be useful for patients with impaired decision-making skills. The drive behind this line of work is that decision-making abilities underlie important aspects of wellness, health, security, and financial and social choices in our daily lives. PMID:27069380
Hornak, Anne M.; Garza Mitchell, Regina L.
Objective: The objective of this article is to delve more deeply into the thought processes of the key decision makers at community colleges and understand how they make decisions. Specifically, this article focuses on the role of the community college president's personal values in decision making. Method: We conducted interviews with 13…
Beach, Lee Roy; Mitchell, Terence R.
Since the early 1950's the principal prescriptive model in the psychological study of decision making has been maximization of Subjective Expected Utility (SEU). This SEU maximization has come to be regarded as a description of how people go about making decisions. However, while observed decision processes sometimes resemble the SEU model,…
In patients with severe uncontrolled asthma, does knowledge of adherence and inhaler technique using electronic monitoring improve clinical decision making? A protocol for a randomised controlled trial.
Mokoka, Matshediso C
Many patients with asthma remain poorly controlled despite the use of inhaled corticosteroids and long-acting beta agonists. Poor control may arise from inadequate adherence, incorrect inhaler technique or because the condition is refractory. Without having an objective assessment of adherence, clinicians may inadvertently add extra medication instead of addressing adherence. This study aims to assess if incorporating objectively recorded adherence from the Inhaler Compliance Assessment (INCA) device and lung function into clinical decision making provides more cost-effective prescribing and improves outcomes.
Dobrajska, Magdalena; Billinger, Stephan; Becker, Markus
We report findings from an analysis of 234 firm boundary decisions that a manufacturing firm has made during a 10 year period. Extensive interviews with all major decision makers located both at the headquarters and subsidiaries allow us to examine (a) who was involved in each boundary decision...
van der Linden, Willem J.
The use of Bayesian decision theory to solve problems in test-based decision making is discussed. Four basic decision problems are distinguished: (1) selection; (2) mastery; (3) placement; and (4) classification, the situation where each treatment has its own criterion. Each type of decision can be
Schuster, Steven R; Pockaj, Barbara A; Bothe, Mary R; David, Paru S; Northfelt, Donald W
Breast cancer is the most common malignancy among women in the United States with the second highest incidence of cancer-related death following lung cancer. The decision-making process regarding adjuvant therapy is a time intensive dialogue between the patient and her oncologist. There are multiple tools that help individualize the treatment options for a patient. Population-based analysis with Adjuvant! Online and genomic profiling with Oncotype DX are two commonly used tools in patients with early stage, node-negative breast cancer. This case report illustrates a situation in which the population-based prognostic and predictive information differed dramatically from that obtained from genomic profiling and affected the patient's decision. In light of this case, we discuss the benefits and limitations of these tools.
Patrick, Nicholas J. M.
Our scientific goal is to understand the process of human decision-making. Specifically, a model of human decision-making in piloting modern commercial aircraft which prescribes optimal behavior, and against which we can measure human sub-optimality is sought. This model should help us understand such diverse aspects of piloting as strategic decision-making, and the implicit decisions involved in attention allocation. Our engineering goal is to provide design specifications for (1) better computer-based decision-aids, and (2) better training programs for the human pilot (or human decision-maker, DM).
Decision-making has evolved recently thanks to the introduction of information and communication technologies in many organizations, which has led to new kinds of decision-making processes, called "collaborative decision-making", at the organizational and cognitive levels. This book looks at the development of the decision-making process in organizations. Decision-aiding and its paradigm of problem solving are defined, showing how decision-makers now need to work in a cooperative way. Definitions of cooperation and associated concepts such as collaboration and coordination are given and a framework of cooperative decision support systems is presented, including intelligent DSS, cooperative knowledge-based systems, workflow, group support systems, collaborative engineering, integrating with a collaborative decision-making model in part or being part of global projects. Several models and experimental studies are also included showing that these new processes have to be supported by new types of tools, several ...
Ofstad, Eirik H; Frich, Jan C; Schei, Edvin; Frankel, Richard M; Gulbrandsen, Pål
To identify and characterize physicians' statements that contained evidence of clinically relevant decisions in encounters with patients in different hospital settings. Qualitative analysis of 50 videotaped encounters from wards, the emergency room (ER) and outpatient clinics in a department of internal medicine at a Norwegian university hospital. Clinical decisions could be grouped in a temporal order: decisions which had already been made, and were brought into the encounter by the physician (preformed decisions), decisions made in the present (here-and-now decisions), and decisions prescribing future actions given a certain course of events (conditional decisions). Preformed decisions were a hallmark in the ward and conditional decisions a main feature of ER encounters. Clinical decisions related to a patient-physician encounter spanned a time frame exceeding the duration of the encounter. While a distribution of decisions over time and space fosters sharing and dilution of responsibility between providers, it makes the decision making process hard to access for patients. In order to plan when and how to involve patients in decisions, physicians need increased awareness of when clinical decisions are made, who usually makes them, and who should make them. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.
Full Text Available In a highly global market, organizations that have the ability to analyze and rapidly respond to the constantly changing marketplace will have the greatest chance of remaining competitive and profitable. Group decision making is the process of arriving at a judgment based upon the feedback of multiple individuals. Due to the importance of the group decision making process, decision making models can be used to establish a systematic means of developing effective group decision making. Once a decision has been made, the members of the group should be willing to accept it and support its implementations.
Kortas, Linda; And Others
The Career Decision Scale, Assessment of Career Decision Making, and Cognitive Differentiation Grid were administered to 598 community college students. Results indicated a relationship between decision-making styles and vocational construct structure. Poorly developed vocational schemas predispose individuals toward dependent and intuitive…
West, Dana R.
Students and their parents/guardians rely on school counselors to provide counseling services based on ethically sound principles. However, there is a lack of empirical evidence about what influences a school counselor's ethical decision making. Ethical decision making for this study was defined as the degree to which decisions pertaining to…
Hagmayer, Y.; Witteman, C.L.M.
Normative causal decision theories argue that people should use their causal knowledge in decision making. Based on these ideas, we argue that causal knowledge and reasoning may support and thereby potentially improve decision making based on expected outcomes, narratives, and even cues. We will
Delegating decision making to those closest to implementation can result in better decisions, more support for improvement initiatives, and increased student performance. Shared decision making depends on capable school leadership, a professional community, instructional guidance mechanisms, knowledge and skills, information sharing, power, and…
Full Text Available of decision support technology. Much variation was found in people’s personal decision-making styles. However, some central themes emerged, such as the importance of sensitivity to the decision-making context, attention to the presentation of information...
von Laffert, Maximilian; Stenzinger, Albrecht; Hummel, Michael; Weichert, Wilko; Lenze, Dido; Warth, Arne; Penzel, Roland; Herbst, Hermann; Kellner, Udo; Jurmeister, Philipp; Schirmacher, Peter; Dietel, Manfred; Klauschen, Frederick
Fluorescence in-situ hybridization (FISH) for the detection of ALK-rearrangements in non-small cell lung cancer (NSCLC) is based on at first sight clear cut-off criteria (≥15% of tumor cells) for split signals (SS) and single red signals (SRS). However, NSCLC with SS-counts around the cut-off may cause interpretation problems. Tissue microarrays containing 753 surgically resected NSCLCs were independently tested for ALK-alterations by FISH and immunohistochemistry (IHC). Our analysis focused on samples with SS/SRS in the range between 10% and 20% (ALK-FISH borderline group). To better understand the role of these samples in routine diagnostics, we performed statistical analyses to systematically estimate the probability of ALK-FISH-misclassification (false negative or positive) for different numbers of evaluated tumor cell nuclei (30, 50, 100, and 200). 94.3% (710/753) of the cases were classified as unequivocally (FISH-negative (93%; 700/753) or positive (1.3%; 10/753) and showed concordant IHC results. 5.7% (43/753) of the samples showed SS/SRS between 10% and 20% of the tumor cells. Out of these, 7% (3/43; ALK-FISH: 14%, 18% and 20%) were positive by ALK-IHC, while 93% (40/43) had no detectable expression of the ALK-protein. Statistical analysis showed that ALK-FISH misclassifications occur frequently for samples with rearrangements between 10% and 20% if ALK-characterization is based on a sharp cut-off point (15%). If results in this interval are defined as equivocal (borderline), statistical sampling-related ALK-FISH misclassifications will occur in less than 1% of the cases if 100 tumor cells are evaluated. While ALK status can be determined robustly for the majority of NSCLC by FISH our analysis showed that ∼6% of the cases belong to a borderline group for which ALK-FISH evaluation has only limited reliability due to statistical sampling effects. These cases should be considered equivocal and therapy decisions should include additional tests and clinical
Hansen, Claus Thorp; Andreasen, Mogens Myrup
In this paper we present the decision score, which is a model of decision-making seen in the engineering designer's perspective of the design process dynamics, where a decision has multiple objects and where it is based on earlier decisions, prediction of consequences and design process progressi...
Best interests decision-making and end-of-life care for patients in permanent vegetative or minimally conscious states (VS/MCS) is a complex area of clinical and legal practice, which is poorly understood by most clinicians, lawyers and members of the public. In recent weeks, the Oxford Shrieval lecture by Mr Justice Baker ('A Matter of Life and Death', 11 October 2016) and its subsequent reporting in the public press has sparked debate on the respective roles of clinicians, the Court of Protection and the Mental Capacity Act 2005 in decisions to withhold or withdraw life-sustaining treatments from patients with disorders of consciousness. The debate became polarised and confused by misquotation and inaccurate terminology, and highlighted a lack of knowledge about how patients in VS/MCS die in the absence of court approval. This article sets out the background and discussion and attempts to give a more accurate representation of the facts. In the spirit of transparency, I present a mortality review of all the patients in VS/MCS who have died under the care of my own unit in the last decade-with or without referral to the court, but always in accordance with the law. These data demonstrate that clinicians regularly undertake best interests decision-making in conjunction with families that may include life and death decisions (sometimes even the withdrawal or withholding of clinically assisted nutrition and hydration); and that these can be made within the current legal framework without necessarily involving the court in all cases. This is the first published case series of its kind. 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/.
Florkowski, Christopher; Don-Wauchope, Andrew; Gimenez, Nuria; Rodriguez-Capote, Karina; Wils, Julien; Zemlin, Annalise
Point-of-care testing (POCT) is the analysis of patient specimens outside the clinical laboratory, near or at the site of patient care, usually performed by clinical staff without laboratory training, although it also encompasses patient self-monitoring. It is able to provide a rapid result near the patient and which can be acted upon immediately. The key driver is the concept that clinical decision making may be delayed when samples are sent to the clinical laboratory. Balanced against this are considerations of increased costs for purchase and maintenance of equipment, staff training, connectivity to the laboratory information system (LIS), quality control (QC) and external quality assurance (EQA) procedures, all required for accreditation under ISO 22870. The justification for POCT depends upon being able to demonstrate that a more timely result (shorter turnaround times (TATs)) is able to leverage a clinically important advantage in decision making compared with the central laboratory (CL). In the four decades since POCT was adapted for the self-monitoring of blood glucose levels by subjects with diabetes, numerous new POCT methodologies have become available, enabling the clinician to receive results and initiate treatment more rapidly. However, these instruments are often operated by staff not trained in laboratory medicine and hence are prone to errors in the analytical phase (as opposed to laboratory testing where the analytical phase has the least errors). In some environments, particularly remote rural settings, the CL may be at a considerable distance and timely availability of cardiac troponins and other analytes can triage referrals to the main centers, thus avoiding expensive unnecessary patient transportation costs. However, in the Emergency Department, availability of more rapid results with POCT does not always translate into shorter stays due to other barriers to implementation of care. In this review, we apply the principles of evidence
Rossi, Antonio; Maione, Paolo; Bareschino, Maria Anna; Schettino, Clorinda; Sacco, Paola Claudia; Ferrara, Marianna Luciana; Castaldo, Vincenzo; Gridelli, Cesare
Lung cancer is the leading cause of cancer mortality worldwide. Non-small cell lung cancer (NSCLC), accounting for about 85% of all lung cancers, includes squamous carcinoma, adenocarcinoma and undifferentiated large cell carcinoma. The majority of patients have advanced disease at diagnosis, and medical treatment is the cornerstone of management. Several randomized trials comparing third-generation platinum-based doublets concluded that all such combinations are comparable in their clinical efficacy, failing to document a difference based on histology. However, recent evidences, arising from the availability of pemetrexed, have shown that histology represents an important variable in the decision making. The major progresses in the understanding cancer biology and mechanism of oncogenesis have allowed the development of several potential molecular targets for cancer treatment such as vascular growth factor and its receptors and epidermal growth factor receptor. Targeted drugs seem to be safer or more effective in a specific histology subtype. All of these data have led to choose the optimal first-line treatment of advanced NSCLC based on histologic diagnosis. However, this scenario raises a diagnostic issue: a specific diagnosis of NSCLC histologic subtype is mandatory. This review will discuss these new evidences in the first-line treatment of advanced NSCLC and their implication in the current clinical decision-making.
Lee, Byung Do
During the diagnostic process of the various oral and maxillofacial lesions, we should consider the following: 'When should we order diagnostic tests? What tests should be ordered? How should we interpret the results clinically? And how should we use this frequently imperfect information to make optimal medical decision?' For the clinicians to make proper judgement, several decision making tools are suggested. This article discusses the concept of the diagnostic accuracy (sensitivity and specificity values) with several decision making tools such as decision matrix, ROC analysis and Bayesian analysis. The article also explain the introductory concept of ORAD program
Ramaekers, Stephan; Kremer, Wim; Pilot, Albert; van Beukelen, Peter; van Keulen, Hanno
Real-life, complex problems often require that decisions are made despite limited information or insufficient time to explore all relevant aspects. Incorporating authentic uncertainties into an assessment, however, poses problems in establishing results and analysing their methodological qualities. This study aims at developing a test on clinical…
Nesbitt, P; Kennedy, Q; Alt, JK; Fricker, RD; Whitaker, L; Yang, J; Appleget, JA; Huston, J; Patton, S
Approved for public release; distribution is unlimited. This research aims to gain insight into optimal wargaming decision-making mechanisms using neurophysiological measures by investigating whether brain activation and visual scan patterns predict attention, perception, and/or decision-making errors through human-in-the-loop wargaming simulation experiments. We investigate whether brain activity and visual scan patterns can explain optimal wargaming decision making and its devel...
General problems associated with social impacts of radiology and decision making is discussed, as the main topics of the meeting. The problem of population is discussed living in areas contaminates with radioactive substances resulting from a major accident or from pest practices. This situation needs decision making process for initiating actions like relocation, resettlement or large-scale decontamination. The roles of various participants in this decision making process and in the communication with the public are considered. (R.P.)
Abstract Decision making is one of the most important and frequent tasks among managers and employees in an organization. Knowledge about more stable cognitive characteristics underlying decision making styles has been requested. This study aimed to examine the relationship between rational decision making style, cognitive style, self efficacy and locus of control. Possible interaction effects in relation to gender were also analyzed. 186 employees at the Ministry of Defence were surveyed...
The article discuss the limits of both the rational actor and the behavioral paradigms in explaining and guiding innovative decision making and outlines a model of economic decision making that in the course of being 'heuristic' (research and discovery oriented) is also 'rational' (in the broad sense of following correct reasoning and scientific methods, non 'biasing'). The model specifies a set of 'rational heuristics' for innovative decision making, for the various sub-processes of problem ...
We are fallible, we have limited computational capabilities, limited access to information, little memory. Moreover, in everyday life, we feel joy, fear, anger, and other emotions that influence our decisions in a little, "calculated" way. Not everyone, however, is also aware that the mistakes we make are often systematic and therefore, in particular circumstances, are foreseeable. Doctors and patients are constantly called upon to make decisions. They need to identify relevant information (for example, the symptoms or outcome of an examination), formulate a judgment (for example a diagnosis), choose an action course among the various possible ones based on one's own preferences (e.g. medication or surgery), so act. The exact size of the medical error is unknown, but probably huge. In fact, the more we investigate and the more we find. Often these mistakes depend on the cognitive process. Any (rational) decision requires, in particular, an assessment of the possible effects of the action it implements; for example how much pleasure or pain it will cause us. In the medical field, too, the principle of informed consent provides that the patient's preferences and values are to guide clinical choices. Yet, not always the preferences that people express before making an experience match with their preferences after living that experience. Some ingenious experiments suggest (in a seemingly paradoxical way) that before a direct experience, people prefer less pain; after that experience they prefer more, but with a better memory.
Alper, Brian S; Fedorowicz, Zbys; van Zuuren, Esther J
To determine how often clinical conclusions derived from Cochrane Reviews have uncertain validity due to review conduct and reporting deficiencies. We evaluated 5142 clinical conclusions in DynaMed (an evidence-based point-of-care clinical reference) based on 4743 Cochrane Reviews. Clinical conclusions with level 2 evidence due to shortcomings in the review's conduct or reporting (rather than deficiencies in the underlying evidence) were confirmed by a DynaMed editor and two Cochrane Review authors. Thirty-one Cochrane Reviews (0.65%) had confirmed deficiencies in conduct and reporting as the reason for classifying 37 assessed clinical conclusions (0.72%) as level 2 evidence. In all cases, it was not feasible for the assessors to specify a clear criticism of the studies included in the reviews. The deficiencies were specific to not accounting for dropouts (2) or inadequate assessment and reporting of allocation concealment (11), other specific trial quality criteria (14), or all trial quality criteria (4). Cochrane Reviews provide high-quality assessment and synthesis of evidence, with fewer than 1% of Cochrane Reviews having limitations which hinder the summary of best current evidence for clinical decision-making. We expect this will further decrease following recent Cochrane quality initiatives. © 2015 Chinese Cochrane Center, West China Hospital of Sichuan University and Wiley Publishing Asia Pty Ltd.
Training family physicians and residents in family medicine in shared decision making to improve clinical decisions regarding the use of antibiotics for acute respiratory infections: protocol for a clustered randomized controlled trial
and physicians, intention to engage in SDM in future clinical encounters will be assessed. Intention-to-treat analyses will be applied and account for the nested design of the trial will be taken into consideration. Discussion DECISION+2 has the potential to reduce antibiotics use for ARIs by priming physicians and patients to share decisional process and empowering patients to make informed, value-based decisions. Trial Registration ClinicalTrials.gov: NCT01116076
Qudrat-Ullah, Hassan; Spector, J Michael
The increasingly complex environment of today's world, characterized by technological innovation and global communication, generates myriads of possible and actual interactions while limited physical and intellectual resources severely impinge on decision makers, be it in the public or private domains. At the core of the decision-making process is the need for quality information that allows the decision maker to better assess the impact of decisions in terms of outcomes, nonlinear feedback processes and time delays on the performance of the complex system invoked. This volume is a timely review on the principles underlying complex decision making, the handling of uncertainties in dynamic envrionments and of the various modeling approaches used. The book consists of five parts, each composed of several chapters: I: Complex Decision Making: Concepts, Theories and Empirical Evidence II: Tools and Techniques for Decision Making in Complex Environments and Systems III: System Dynamics and Agent-Based Modeling IV:...
Bossaerts, Peter; Murawski, Carsten
The rationality principle postulates that decision-makers always choose the best action available to them. It underlies most modern theories of decision-making. The principle does not take into account the difficulty of finding the best option. Here, we propose that computational complexity theory (CCT) provides a framework for defining and quantifying the difficulty of decisions. We review evidence showing that human decision-making is affected by computational complexity. Building on this evidence, we argue that most models of decision-making, and metacognition, are intractable from a computational perspective. To be plausible, future theories of decision-making will need to take into account both the resources required for implementing the computations implied by the theory, and the resource constraints imposed on the decision-maker by biology. Copyright © 2017 Elsevier Ltd. All rights reserved.
Stiegler, Marjorie Podraza; Tung, Avery
The quality and safety of health care are under increasing scrutiny. Recent studies suggest that medical errors, practice variability, and guideline noncompliance are common, and that cognitive error contributes significantly to delayed or incorrect diagnoses. These observations have increased interest in understanding decision-making psychology.Many nonrational (i.e., not purely based in statistics) cognitive factors influence medical decisions and may lead to error. The most well-studied include heuristics, preferences for certainty, overconfidence, affective (emotional) influences, memory distortions, bias, and social forces such as fairness or blame.Although the extent to which such cognitive processes play a role in anesthesia practice is unknown, anesthesia care frequently requires rapid, complex decisions that are most susceptible to decision errors. This review will examine current theories of human decision behavior, identify effects of nonrational cognitive processes on decision making, describe characteristic anesthesia decisions in this context, and suggest strategies to improve decision making.
Kárný, Miroslav; Wolpert, David
This volume focuses on uncovering the fundamental forces underlying dynamic decision making among multiple interacting, imperfect and selﬁsh decision makers. The chapters are written by leading experts from different disciplines, all considering the many sources of imperfection in decision making, and always with an eye to decreasing the myriad discrepancies between theory and real world human decision making. Topics addressed include uncertainty, deliberation cost and the complexity arising from the inherent large computational scale of decision making in these systems. In particular, analyses and experiments are presented which concern: • task allocation to maximize “the wisdom of the crowd”; • design of a society of “edutainment” robots who account for one anothers’ emotional states; • recognizing and counteracting seemingly non-rational human decision making; • coping with extreme scale when learning causality in networks; • efﬁciently incorporating expert knowledge in personalized...
Kureychik, V. M.; Safronenkova, I. B.
Uncertainty is an essential part of a decision-making procedure. The paper deals with the problem of decision-making under criteria uncertainty. In this context, decision-making under uncertainty, types and conditions of uncertainty were examined. The decision-making problem under uncertainty was formalized. A modification of the mathematical decision support method under uncertainty via ontologies was proposed. A critical distinction of the developed method is ontology usage as its base elements. The goal of this work is a development of a decision-making method under criteria uncertainty with the use of ontologies in the area of multilayer board designing. This method is oriented to improvement of technical-economic values of the examined domain.
Reduction in prices now makes it possible for almost any institution to use computer graphics for administrative decision making and research. Current and potential uses of computer graphics in these two areas are discussed. (JN)
Dutilh, Gilles; Rieskamp, Jörg
Perceptual and preferential decision making have been studied largely in isolation. Perceptual decisions are considered to be at a non-deliberative cognitive level and have an outside criterion that defines the quality of decisions. Preferential decisions are considered to be at a higher cognitive level and the quality of decisions depend on the decision maker's subjective goals. Besides these crucial differences, both types of decisions also have in common that uncertain information about the choice situation has to be processed before a decision can be made. The present work aims to acknowledge the commonalities of both types of decision making to lay bare the crucial differences. For this aim we examine perceptual and preferential decisions with a novel choice paradigm that uses the identical stimulus material for both types of decisions. This paradigm allows us to model the decisions and response times of both types of decisions with the same sequential sampling model, the drift diffusion model. The results illustrate that the different incentive structure in both types of tasks changes people's behavior so that they process information more efficiently and respond more cautiously in the perceptual as compared to the preferential task. These findings set out a perspective for further integration of perceptual and preferential decision making in a single ramework.
Gregory, M M
Based on the preceding factors, a profile can be made for each light. The profile should include the following information: product literature with detailed information about the light, the average score from each of the six categories on the questionnaire, a summary of positive and negative comments from the questionnaire (recurring comments can identify significant factors), recommendations from other hospitals using the light, warranty and service information and any pertinent information about the vendor and manufacturer, information or comments from the clinical engineer, the purchasing agent, and the architect/engineer, and information about possible purchase agreements. Once the profiles of the lights are finished, present them to the OR committee or group charged with making the final decision. The information will enable the group to compare the lights and will serve as a basis for either the final purchase or a detailed bid specification. If cost is a major factor in the decision, the evaluation results can be used to justify purchasing lights that are more expensive but that the users believe are clearly superior. This constitutes the "professional justification" that some government institutions require to circumvent regulations that require buying the low-bid product. Although the result of this selection process is clearly a subjective decision, it is an informed subjective decision. Once the lights are installed, the staff members' satisfaction with the lights will not be based on objective criteria but on the same subjective opinions that were used to justify the selection.
Full Text Available It is not known whether patients with juvenile myoclonic epilepsy (JME differ from healthy people in decision making under risk, i.e., when the decision-making context offers explicit information about options, probabilities, and consequences already from the beginning. In this study, we adopted the Game of Dice Task-Double to investigate decision making under risk in a group of 36 patients with JME (mean age 25.25/SD 5.29 years and a group of 38 healthy controls (mean age 26.03/SD 4.84 years. Participants also underwent a comprehensive neuropsychological assessment focused on frontal executive functions. Significant group differences were found in tests of psychomotor speed and divided attention, with the patients scoring lower than the controls. Importantly, patients made risky decisions more frequently than controls. In the patient group, poor decision making was associated with poor executive control, poor response inhibition, and a short interval since the last seizure episode. Executive control and response inhibition could predict 42% of variance in the frequency of risky decisions. This study indicates that patients with JME with poorer executive functions are more likely to make risky decisions than healthy controls. Decision making under risk is of major importance in every-day life, especially with regard to treatment decisions and adherence to long-term medical therapy. Since even a single disadvantageous decision may have long-lasting consequences, this finding is of high relevance.
Unterberger, Iris; Zamarian, Laura; Prieschl, Manuela; Bergmann, Melanie; Walser, Gerald; Luef, Gerhard; Javor, Andrija; Ransmayr, Gerhard; Delazer, Margarete
It is not known whether patients with juvenile myoclonic epilepsy (JME) differ from healthy people in decision making under risk, i.e., when the decision-making context offers explicit information about options, probabilities, and consequences already from the beginning. In this study, we adopted the Game of Dice Task-Double to investigate decision making under risk in a group of 36 patients with JME (mean age 25.25/SD 5.29 years) and a group of 38 healthy controls (mean age 26.03/SD 4.84 years). Participants also underwent a comprehensive neuropsychological assessment focused on frontal executive functions. Significant group differences were found in tests of psychomotor speed and divided attention, with the patients scoring lower than the controls. Importantly, patients made risky decisions more frequently than controls. In the patient group, poor decision making was associated with poor executive control, poor response inhibition, and a short interval since the last seizure episode. Executive control and response inhibition could predict 42% of variance in the frequency of risky decisions. This study indicates that patients with JME with poorer executive functions are more likely to make risky decisions than healthy controls. Decision making under risk is of major importance in every-day life, especially with regard to treatment decisions and adherence to long-term medical therapy. Since even a single disadvantageous decision may have long-lasting consequences, this finding is of high relevance.
Daniel L. Schmoldt; David L. Peterson
Public land managers must treat multiple values coincidentally in time and space, which requires the participation of multiple resource specialists and consideration of diverse clientele interests in the decision process. This implies decision making that includes multiple participants, both internally and externally. Decades of social science research on decision...
Five types of decision-uncertainty are distinguished: uncertainty of consequences, of values, of demarcation, of reliance, and of co-ordination. Strategies are proposed for each type of uncertainty. The general conclusion is that it is meaningful for decision theory to treat cases with greater uncertainty than the textbook case of 'decision-making under uncertainty'. (au)
Brotherton, Ailsa; Abbott, Janice
In this article we present the findings of an exploration of mothers' discourses on decision making for gastrostomy placement for their child. Exploring in-depth interviews of a purposive sample, we analyzed the mothers' discourses of the decision-making process to understand how their experiences of the process influenced their subsequent constructions of decision making. Mothers negotiated decision making by reflecting on their personal experiences of feeding their child, either orally or via a tube, and interwove their background experiences with the communications from members of the health care team until a decision was reached. Decision making was often fraught with difficulty, resulting in anxiety and guilt. Experiences of decision making ranged from perceived coercion to true choice, which encompasses a truly child-centered decision. The resulting impact of the decision-making process on the mothers was profound. We conclude with an exploration of the implications for clinical practice and describe how health care professionals can support mothers to ensure that decision-making processes for gastrostomy placement in children are significantly improved.
Medical decision-making studies continue to focus on two questions: How do physicians make decisions and how should physicians make decisions. Researchers pursuing the first question emphasize human cognitive processes and the programming of symbol systems to model the observed human behaviour. Those researchers concentrating on the second question assume that there is a standard of performance against which physicians' decisions can be judged, and to help the physician improve his performance an array of tools is proposed. These tools include decision trees, Bayesian analysis, decision matrices, receiver operating characteristic (ROC) analysis, and cost-benefit considerations including utility measures. Both questions must be answered in an ethical context where ethics and decision analysis are intertwined. (author)
Israelsen, Poul; Jørgensen, Brian
which distorts the economic effects of modularization at the level of the individual product. This has the implication that decisions on modularization can only be made by top management if decision authority and relevant information are to be aligned. To overcome this problem, we suggest a solution...... that aligns the descriptions of the economic consequences of modularization at the project and portfolio level which makes it possible to decentralize decision making while making sure that local goals are congruent with the global ones in order to avoid suboptimal behaviour. Keywords: Modularization......; Accounting; Cost allocation; Decision rule; Decentralization...
This book offers an in-depth and comprehensive introduction to the priority methods of intuitionistic preference relations, the consistency and consensus improving procedures for intuitionistic preference relations, the approaches to group decision making based on intuitionistic preference relations, the approaches and models for interactive decision making with intuitionistic fuzzy information, and the extended results in interval-valued intuitionistic fuzzy environments.
Zavadskas, Edmundas Kazimieras; Govindan, K.; Antucheviciene, Jurgita
Formal decision-making methods can be used to help improve the overall sustainability of industries and organisations. Recently, there has been a great proliferation of works aggregating sustainability criteria by using diverse multiple criteria decision-making (MCDM) techniques. A number of revi...
Long, Arwen B.; Kuhn, Cynthia M.; Platt, Michael L.
Some people love taking risks, while others avoid gambles at all costs. The neural mechanisms underlying individual variation in preference for risky or certain outcomes, however, remain poorly understood. Although behavioral pathologies associated with compulsive gambling, addiction and other psychiatric disorders implicate deficient serotonin signaling in pathological decision making, there is little experimental evidence demonstrating a link between serotonin and risky decision making, in ...
Coenen, Frans; Huitema, Dave; Woltjer, Johan
This chapter concerns the impact of public involvement in public decision-making processes as related to household consumption patterns, and the impact on consumer behaviour of active participation.1 The call for participatory decision-making is common in the field of sustainable consumption (Murphy
Yacoubian, Hagop A.
Scientifically literate citizens must be able to engage in making decisions on science-based social issues. In this paper, I start by showing examples of science curricula and policy documents that capitalise the importance of engaging future citizens in decision-making processes whether at the personal or at the societal levels. I elucidate the…
Fuzzy sets and interval analysis tools to make computations and solve optimisation problems are presented. Fuzzy and interval extensions of Decision Theory criteria for decision-making under parametric uncertainty of prior information (probabilities, payoffs) are developed. An interval probability approach to the mean-value criterion is proposed. (author)
Rose, Stephen A.
Computer software that will help intermediate and secondary social studies students learn to make rational decisions about personal and societal concerns are described. The courseware places students in the roles of business managers who make decisions about operating their firms. (RM)
Backus, G.B.C.; Eidman, V.R.; Dijkhuizen, A.A.
Relevant portions of the risk literature are reviewed, relating them to observed behaviour in farm decision-making. Relevant topics for applied agricultural risk research are proposed. The concept of decision making under risk and uncertainty is discussed by reviewing the theory of Subjective
Ismariah Ahmad; Rohana Abd Rahman; Roda Jean-Marc; Lim Hin Fui; Mohd Parid Mamat
Sound decision-making requires quality information. Poor information does not help in decision making. Among the sources of low quality information, an important cause is inadequate and inappropriate sampling. In this paper we illustrate the case of information collected on timber prices.
Brazer, S. David; Rich, William; Ross, Susan A.
Purpose: The dual purpose of this paper is to determine how superintendents in US school districts work with stakeholders in the decision-making process and to learn how different choices superintendents make affect decision outcomes. Design/methodology/approach: This multiple case study of three school districts employs qualitative methodology to…
The problem. Educational leaders face challenges in the 21st century, make numerous decisions daily, and have the choice to make decisions based on ethics. Educational leaders may follow a corporate model regarding expenses and revenues while ignoring the best interests of children and their academic achievement. The alternative to the corporate…
This document describes some parameters and fundamental criteria which should be taken into account by the safety authorities in the decision making. Added to these principles, internal procedures, devoted to an integrated framework of decision making, should be implemented. This presentation is based on the study realized by an experts Group of the Nuclear Energy Agency. (A.L.B.)
Simon, Herbert A.
Describes the current state of knowledge about human decision-making and problem-solving processes, explaining recent developments and their implications for management and management training. Rational goal-setting is the key to effective decision making and accomplishment. Bounded rationality is a realistic orientation, because the world is too…
M.J. Bruins (Marjan); G. Ruijs (G.); M.J.H.M. Wolfhagen; P. Bloembergen (Peter); J.E.C.M. Aarts (Jos)
textabstractBackground: Clinicians view the accuracy of test results and the turnaround time as the two most important service aspects of the clinical microbiology laboratory. Because of the time needed for the culturing of infectious agents, final hardcopy culture results will often be available
Reynolds, Charles H.
Sound ethical decisions depend on clear problem definition, careful review of alternatives, consideration of consequences, and thoughtful application of relevant principles of responsibility. Often they also require a willingness to receive corrective insight and to check judgments with moral intuitions. Higher education has a special…
professionals will be becoming more adept at scripting, modeling, graphical and statistical displays. Decision makers may, similarly, be less likely to shy...elsewhere in this proceedings (Sanchez 2014) simulation can be the core for model-driven big data and inferential decision-making. We need to stake... descriptive , not prescriptive.” In our field, we deal with prospective decision making. We have an advantage in this area: since our output data are
Decision making is traditionally viewed as a rational process where reason calculates the best way to achieve the goal. Investigations from different areas of cognitive science have shown that human decisions and actions are much more influenced by intuition and emotional responses then it was previously thought. In this paper I examine the role of emotion in decision making, particularly Damasio’s hypothesis of somatic markers and Green’s dual process theory of moral judgment. I conclude the...
Common features between the domains of behavioural decision making and suggestional processes are discussed. These features are allocated in two aspects. First, behavioural decision making and suggestional processes are traditionally considered to provoke inadequate human behaviour. In this article arguments are put forward against this interpretation: Actions induced by non-rational decisions and / or by suggestional processes often have adaptive functions. Second, two common themat...
Blakemore, Sarah-Jayne; Robbins, Trevor W
Adolescence is characterized by making risky decisions. Early lesion and neuroimaging studies in adults pointed to the ventromedial prefrontal cortex and related structures as having a key role in decision-making. More recent studies have fractionated decision-making processes into its various components, including the representation of value, response selection (including inter-temporal choice and cognitive control), associative learning, and affective and social aspects. These different aspects of decision-making have been the focus of investigation in recent studies of the adolescent brain. Evidence points to a dissociation between the relatively slow, linear development of impulse control and response inhibition during adolescence versus the nonlinear development of the reward system, which is often hyper-responsive to rewards in adolescence. This suggests that decision-making in adolescence may be particularly modulated by emotion and social factors, for example, when adolescents are with peers or in other affective ('hot') contexts.
This paper suggests incorporating affective considerations into decision making theory and insurance decision in particular. I describe a decision maker with two internal accounts - the rational account and the mental account. The rational account decides on insurance to maximize expected (perceived) utility, while the mental account chooses risk perceptions which then affect the perceived expected utility. The two accounts interact to reach a decision which is composed of both risk perceptio...
Andrei Sergeevich Emelyanov
Full Text Available This article is devoted to an extensive and modern area of scientific knowledge – Decision theory. The author comprehends and analyzes critically the methodological bases of the Decision theory, he thinks, it rejects the most important thing – a human. In the article the reconstruction of historical development in the Decision theory is considered and also existential factors and feelings are discussed, which appear in human being and operate the situation of decision-making.
Abida, Wassim; Armenia, Joshua; Gopalan, Anuradha; Brennan, Ryan; Walsh, Michael; Barron, David; Danila, Daniel; Rathkopf, Dana; Morris, Michael; Slovin, Susan; McLaughlin, Brigit; Curtis, Kristen; Hyman, David M; Durack, Jeremy C; Solomon, Stephen B; Arcila, Maria E; Zehir, Ahmet; Syed, Aijazuddin; Gao, Jianjiong; Chakravarty, Debyani; Vargas, Hebert Alberto; Robson, Mark E; Joseph, Vijai; Offit, Kenneth; Donoghue, Mark T A; Abeshouse, Adam A; Kundra, Ritika; Heins, Zachary J; Penson, Alexander V; Harris, Christopher; Taylor, Barry S; Ladanyi, Marc; Mandelker, Diana; Zhang, Liying; Reuter, Victor E; Kantoff, Philip W; Solit, David B; Berger, Michael F; Sawyers, Charles L; Schultz, Nikolaus; Scher, Howard I
A long natural history and a predominant osseous pattern of metastatic spread are impediments to the adoption of precision medicine in patients with prostate cancer. To establish the feasibility of clinical genomic profiling in the disease, we performed targeted deep sequencing of tumor and normal DNA from patients with locoregional, metastatic non-castrate, and metastatic castration-resistant prostate cancer (CRPC). Patients consented to genomic analysis of their tumor and germline DNA. A hybridization capture-based clinical assay was employed to identify single nucleotide variations, small insertions and deletions, copy number alterations and structural rearrangements in over 300 cancer-related genes in tumors and matched normal blood. We successfully sequenced 504 tumors from 451 patients with prostate cancer. Potentially actionable alterations were identified in DNA damage repair (DDR), PI3K, and MAP kinase pathways. 27% of patients harbored a germline or a somatic alteration in a DDR gene that may predict for response to PARP inhibition. Profiling of matched tumors from individual patients revealed that somatic TP53 and BRCA2 alterations arose early in tumors from patients who eventually developed metastatic disease. In contrast, comparative analysis across disease states revealed that APC alterations were enriched in metastatic tumors, while ATM alterations were specifically enriched in CRPC. Through genomic profiling of prostate tumors representing the disease clinical spectrum, we identified a high frequency of potentially actionable alterations and possible drivers of disease initiation, metastasis and castration-resistance. Our findings support the routine use of tumor and germline DNA profiling for patients with advanced prostate cancer, for the purpose of guiding enrollment in targeted clinical trials and counseling families at increased risk of malignancy.
Brady, Anne-Marie; Ennis, Shauna; Prendergast, Maebh; Quirke, Mary; Bhangu, Jas; Lynch, Aine; Byrne, Gobnait
Introduction: The out-of-hours period is associated with less favourable patient health outcomes as well as unpredictable workloads and reduced support structures for clinical activity. In particular, appropriate skill mix, staff numbers, resources, communication structures and access to diagnostic services can influence patient safety and risk. As part of continued efforts to improve patient care and hospital management, one major academic hospital is in Ireland has been engaged in work re-d...
Boland, Laura; McIsaac, Daniel I; Lawson, Margaret L
To explore multiple stakeholders' perceived barriers to and facilitators of implementing shared decision making and decision support in a tertiary paediatric hospital. An interpretive descriptive qualitative study was conducted using focus groups and interviews to examine senior hospital administrators', clinicians', parents' and youths' perceived barriers to and facilitators of shared decision making and decision support implementation. Data were analyzed using inductive thematic analysis. Fifty-seven stakeholders participated. Six barrier and facilitator themes emerged. The main barrier was gaps in stakeholders' knowledge of shared decision making and decision support. Facilitators included compatibility between shared decision making and the hospital's culture and ideal practices, perceptions of positive patient and family outcomes associated with shared decision making, and positive attitudes regarding shared decision making and decision support. However, youth attitudes regarding the necessity and usefulness of a decision support program were a barrier. Two themes were both a barrier and a facilitator. First, stakeholder groups were uncertain which clinical situations are suitable for shared decision making