Showing papers in "Medical Decision Making in 2014"
TL;DR: A modified Delphi consensus process is reported to agree on IPDASi (v3.0) items that should be considered as minimum standards for PDA certification, for inclusion in the refined IPDasi ( v4.0).
Abstract: Objective. The IPDAS Collaboration has developed a checklist and an instrument (IPDASi v3.0) to assess the quality of patient decision aids (PDAs) in terms of their development process and shared decision-making design components. Certification of PDAs is of growing interest in the US and elsewhere. We report a modified Delphi consensus process to agree on IPDASi (v3.0) items that should be considered as minimum standards for PDA certification, for inclusion in the refined IPDASi (v4.0). Methods. A 2-stage Delphi voting process considered the inclusion of IPDASi (v3.0) items as minimum standards. Item scores and qualitative comments were analyzed, followed by expert group discussion. Results. One hundred and one people voted in round 1; 87 in round 2. Forty-seven items were reduced to 44 items across 3 new categories: 1) qualifying criteria, which are required in order for an intervention to be considered a decision aid (6 items); 2) certification criteria, without which a decision aid is judged to have a high risk of harmful bias (10 items); and 3) quality criteria, believed to strengthen a decision aid but whose omission does not present a high risk of harmful bias (28 items). Conclusions. This study provides preliminary certification criteria for PDAs. Scoring and rating processes need to be tested and finalized. However, the process of appraising the quality of the clinical evidence reported by the PDA should be used to complement these criteria; the proposed standards are designed to rate the quality of the development process and shared decision-making design elements, not the quality of the PDA’s clinical content.
358 citations
TL;DR: This work describes a novel nonparametric regression-based method for estimating partial EVPI that requires only the probabilistic sensitivity analysis sample and is applicable in a model of any complexity and with any specification of input parameter distribution.
Abstract: The partial expected value of perfect information (EVPI) quantifies the expected benefit of learning the values of uncertain parameters in a decision model. Partial EVPI is commonly estimated via a 2-level Monte Carlo procedure in which parameters of interest are sampled in an outer loop, and then conditional on these, the remaining parameters are sampled in an inner loop. This is computationally demanding and may be difficult if correlation between input parameters results in conditional distributions that are hard to sample from. We describe a novel nonparametric regression-based method for estimating partial EVPI that requires only the probabilistic sensitivity analysis sample (i.e., the set of samples drawn from the joint distribution of the parameters and the corresponding net benefits). The method is applicable in a model of any complexity and with any specification of input parameter distribution. We describe the implementation of the method via 2 nonparametric regression modeling approaches, the Generalized Additive Model and the Gaussian process. We demonstrate in 2 case studies the superior efficiency of the regression method over the 2-level Monte Carlo method. R code is made available to implement the method.
217 citations
TL;DR: It is hypothesized that willingness to participate is not very high because people are uninformed about participating, particularly in non–English-speaking Hispanics, and improved understanding of cultural differences that can be addressed by physicians may restore faith, comprehension, and acceptability of clinical trials by all patients.
Abstract: Background. Participation in cancer clinical trials is low, particularly in racial and ethnic minorities in some cases, which has negative consequences for the generalizability for study findings. The objective of this study was to determine what factors are associated with patients’ participation or willingness to participate and whether these factors vary by race/ethnicity. Design or Methods. White, Hispanic, and black participants were obtained through the Florida cancer registry and who were diagnosed with breast, lung, colorectal, or prostate cancer (N = 1100). Participants were surveyed via telephone to obtain demographic information, past participation, and willingness to participate in clinical trials, as well as barriers and facilitators to participation. Logistic and Poisson regressions were performed. Results. Respondents were on average 67.4 years old, 42.7% were male, and 50.1% were married. In this population, 7.7% of respondents had participated in a clinical trial, and 36.5% stated that th...
139 citations
TL;DR: SURE shows adequate psychometric properties in a primary care population with a low prevalence of clinically significant decisional conflict, and has the potential to be a useful screening tool for practitioners, responding to the growing need for detecting clinically significant Decisional Conflict in patients.
Abstract: Background: We sought to determine the psychometric properties of SURE, a 4-item checklist designed to screen for clinically significant decisional conflict in clinical practice. Methods: This study was a secondary analysis of a clustered randomized trial assessing the effect of DECISION+2, a 2-hour online tutorial followed by a 2-hour interactive workshop on shared decision making, on decisions to use antibiotics for acute respiratory infections. Patients completed SURE and also the Decisional Conflict Scale (DCS), as the gold standard, after consultation. We evaluated internal consistency of SURE using the Kuder-Richardson 20 coefficient (KR-20). We compared DCS and SURE scores using the Spearman correlation coefficient. We assessed sensitivity and specificity of SURE scores (cut-off score ≤3 out of 4) by identifying patients with and without clinically significant decisional conflict (DCS score >37.5 on a scale of 0–100). Results: Of the 712 patients recruited during the trial, 654 completed both tools...
109 citations
TL;DR: Icon type influences both risk perceptions and risk recall, with restroom icons in particular resulting in improved outcomes, however, optimal icon types may depend on numeracy and/or graphical literacy skills.
Abstract: Background Research has demonstrated that icon arrays (also called “pictographs”) are an effective method of communicating risk statistics and appear particularly useful to less numerate and less
106 citations
TL;DR: DCEs can be used to investigate preferences for health profiles and to estimate utility weights for multi-attribute utility instruments, and Australian cost-utility analyses can now use domestic SF-6D weights.
Abstract: Background. SF-6D utility weights are conventionally produced using a standard gamble (SG). SG-derived weights consistently demonstrate a floor effect not observed with other elicitation techniques. Recent advances in discrete choice methods have allowed estimation of utility weights. The objective was to produce Australian utility weights for the SF-6D and to explore the application of discrete choice experiment (DCE) methods in this context. We hypothesized that weights derived using this method would reflect the largely monotonic construction of the SF-6D. Methods. We designed an online DCE and administered it to an Australia-representative online panel (n = 1017). A range of specifications investigating nonlinear preferences with respect to additional life expectancy were estimated using a random-effects probit model. The preferred model was then used to estimate a preference index such that full health and death were valued at 1 and 0, respectively, to provide an algorithm for Australian cost-utility...
101 citations
TL;DR: EQ-5D valuation studies conducted to date have varied widely in their design and in the resulting scoring algorithms, and the Checklist for Reporting Valuation Studies of the EQ- 5D (CREATE) for those conducting valuation studies is proposed.
Abstract: Background. There has been a growing interest around the world in developing country-specific scoring algorithms for the EQ-5D. This study systematically reviews all existing EQ-5D valuation studies to highlight their strengths and limitations, explores heterogeneity in observed utilities using meta-regression, and proposes a methodological checklist for reporting EQ-5D valuation studies. Methods. We searched Medline, EMBASE, the National Health Service Economic Evaluation Database (NHS EED) via Wiley’s Cochrane Library, and Wiley’s Health Economic Evaluation Database from inception through November 2012, as well as bibliographies of key papers and the EuroQol Plenary Meeting Proceedings from 1991 to 2012 for English-language reports of EQ-5D valuation studies. Two reviewers independently screened the titles and abstracts for relevance. Three reviewers performed data extraction and compared the characteristics and scoring algorithms developed in the included valuation studies. Results. Of the 31 studies i...
79 citations
TL;DR: Recommendations on the use of methods to adjust survival estimates in the presence of treatment switching in the context of economic evaluations are presented and an analysis framework is presented that aims to increase the probability that suitable adjustment methods can be identified on a case-by-case basis.
Abstract: Background. Treatment switching commonly occurs in clinical trials of novel interventions in the advanced or metastatic cancer setting. However, methods to adjust for switching have been used incon...
77 citations
TL;DR: This article develops a general framework to guide the use of subgroup cost-effectiveness analysis for decision making in a collectively funded health system, and presents the expected net benefits under current and perfect information when subgroups are defined based on the use and combination of 6 binary covariates.
Abstract: This article develops a general framework to guide the use of subgroup cost-effectiveness analysis for decision making in a collectively funded health system. In doing so, it addresses 2 key policy questions, namely, the identification and selection of subgroups, while distinguishing 2 sources of potential value associated with heterogeneity. These are 1) the value of revealing the factors associated with heterogeneity in costs and outcomes using existing evidence (static value) and 2) the value of acquiring further subgroup-related evidence to resolve the uncertainty given the current understanding of heterogeneity (dynamic value). Consideration of these 2 sources of value can guide subgroup-specific treatment decisions and inform whether further research should be conducted to resolve uncertainty to explain variability in costs and outcomes. We apply the proposed methods to a cost-effectiveness analysis for the management of patients with acute coronary syndrome. This study presents the expected net benefits under current and perfect information when subgroups are defined based on the use and combination of 6 binary covariates. The results of the case study confirm the theoretical expectations. As more subgroups are considered, the marginal net benefit gains obtained under the current information show diminishing marginal returns, and the expected value of perfect information shows a decreasing trend. We present a suggested algorithm that synthesizes the results to guide policy.
74 citations
TL;DR: A tariff providing standard utility scores for caring situations described with the CarerQol-7D facilitates the inclusion of informal care in economic evaluations.
Abstract: design with priors obtained from a pilot study (N =1 04) was used. Data were analyzed with a panel mixed multinomial parameter model including main and interaction effects of the attributes. Results. The utility attached to informal care situations was significantly higher when this situation was more attractive in terms of fewer problems and more fulfillment or support. The interaction term between the CarerQol-7D dimensions physical health and mental health problems also significantly explained this utility. The tariff was constructed by adding up the relative utility weights per category of all CarerQol-7D dimensions and the interaction term. Conclusions. We obtained a tariff providing standard utility scores for caring situations described with the CarerQol-7D. This facilitates the inclusion of informal care in economic evaluations. Key words: discrete choice; informal care; CarerQol instrument; care-related quality of life; tariff. (Med Decis Making 2014;34:84–96)
72 citations
TL;DR: Providing numeric AE-likelihood information (compared with nonnumeric) is likely to increase risk comprehension across numeracy and age levels.
Abstract: Background. How drug adverse events (AEs) are communicated in the United States may mislead consumers and result in low adherence. Requiring written information to include numeric AE-likelihood inf...
TL;DR: This study demonstrates the feasibility of conducting economic evaluations in the context of rare diseases by demonstrating the cost-effectiveness of eculizumab for the treatment of paroxysmal nocturnal hemoglobinuria and its associated opportunity costs.
Abstract: Background. Both ethical and economics concerns have been raised with respect to the funding of drugs for rare diseases. This article reports both the cost-effectiveness of eculizumab for the treatment of paroxysmal nocturnal hemoglobinuria (PNH) and its associated opportunity costs. Methods. Analysis compared eculizumab plus current standard of care v. current standard of care from a publicly funded health care system perspective. A Markov model covered the major consequences of PNH and treatment. Cost-effectiveness was assessed in terms of the incremental cost per life year and per quality-adjusted life year (QALY) gained. Opportunity costs were assessed by the health gains foregone and the alternative uses for the additional resources. Results. Eculizumab is associated with greater life years (1.13), QALYs (2.45), and costs (CAN$5.24 million). The incremental cost per life year and per QALY gained is CAN$4.62 million and CAN$2.13 million, respectively. Based on established thresholds, the opportunity c...
TL;DR: This article shows how to implement the Lu and Ades model in the frequentist generalized linear mixed model and demonstrates how centering the covariates for random effects estimation within each trial can yield correct estimation of random effects.
Abstract: In the past decade, a new statistical method-network meta-analysis-has been developed to address limitations in traditional pairwise meta-analysis. Network meta-analysis incorporates all available evidence into a general statistical framework for comparisons of multiple treatments. Bayesian network meta-analysis, as proposed by Lu and Ades, also known as "mixed treatments comparisons," provides a flexible modeling framework to take into account complexity in the data structure. This article shows how to implement the Lu and Ades model in the frequentist generalized linear mixed model. Two examples are provided to demonstrate how centering the covariates for random effects estimation within each trial can yield correct estimation of random effects. Moreover, under the correct specification for random effects estimation, the dummy coding and contrast basic parameter coding schemes will yield the same results. It is straightforward to incorporate covariates, such as moderators and confounders, into the generalized linear mixed model to conduct meta-regression for multiple treatment comparisons. Moreover, this approach may be extended easily to other types of outcome variables, such as continuous, counts, and multinomial.
TL;DR: Light is shed on the experience of very old adults in health care decision making from their own point of view to deepen the understanding of their potentially modifiable barriers to participation.
Abstract: Background. Some elderly people receive tests or interventions from which they have low likelihood of benefit or for which the goal is not aligned with their values. Engaging these patients in the decision process is one potential approach to improve the individualization of care. Yet some clinicians perceive and some survey data suggest that older adults prefer not to participate in the decision-making process. Those preferences, however, may be formed based on an experience in which factors, such as communication issues, were barriers to participation. Our goal was to shed light on the experience of very old adults in health care decision making from their own point of view to deepen our understanding of their potentially modifiable barriers to participation. Design and Methods. Semistructured interviews of participants aged 80 and older (n = 29, 59% women and 21% black) were analyzed using the constant comparative method in a grounded theory approach to describe decision making in clinic visits from th...
TL;DR: Modeling of EQ-5D from clinical measures is best performed directly using the bespoke mixture model, which substantially outperforms the indirect method in this example.
Abstract: Background: Analysts often need to estimate health state utility values as a function of other outcome measures. Utility values like EQ-5D have several unusual characteristics that make standard statistical methods inappropriate. We have developed a bespoke approach based on mixture models to directly estimate EQ-5D. An indirect method, “response mapping”, first estimates the level on each of the five dimensions of the EQ-5D descriptive system and then calculates the expected tariff score. These methods have never previously been compared.
Methods: We use a large observational database of patients diagnosed with Rheumatoid Arthritis (n=100,398 observations). Direct estimation of UK EQ-5D scores as a function of Health Assessment Questionnaire (HAQ), pain and age was performed using a limited dependent variable mixture model. Indirect modelling was undertaken using a set of generalized ordered probit models with expected tariff scores calculated mathematically. Linear regression was reported for comparison purposes.
Results: The linear model fits poorly, particularly at the extremes of the distribution. Both the bespoke mixture model and the generalized ordered probit approach offer improvements in fit over the entire range of EQ-5D. Mean average error is 10% and 5% lower compared to the linear model respectively. Root mean squared error is 3% and 2% lower. The mixture model demonstrates superior performance to the indirect method across almost the entire range of pain and HAQ.
Limitations: There is limited data from patients in the most extreme HAQ health states.
Conclusions: Modelling of EQ-5D from clinical measures is best performed directly using the bespoke mixture model. This substantially outperforms the indirect method in this example. Linear models are inappropriate, suffer from systematic bias and generate values outside the feasible
range.
TL;DR: There seems to be no benefit to adding a sleep dimension to the EQ-5D, and research is required to explore the method of adding dimensions to existing descriptive systems of health.
Abstract: Background and Objective. The generic preference-based measures (GPBMs) of health have been widely used to obtain health utility scores for calculating qualityadjusted life-years (QALYs) for economic evaluations. It has been recognized that GPBMs may miss relevant or important dimensions of health for some specific medical conditions. The objective of this study is to explore the effect of extending the current EQ-5D descriptive system by adding a sleep dimension. Methods. A new instrument, EQ-5D 1Sleep, is proposed by adding a sleep dimension to the EQ-5D. Based on an orthogonal design, 18 EQ5D 1Sleep states and EQ-5D states were selected and a valuation study was undertaken whereby 160 members of the generic public in South Yorkshire, UK, were interviewed using time tradeoff (TTO). Econometric models have been fitted to the data. Two null hypotheses were tested: 1) the coefficient for the sleep dimension is not significant; and 2) the inclusion of the sleep dimension has no impact on the way people value the original dimensions of EQ-5D. Results and Conclusions. The results support these two null hypotheses. There seems to be no benefit to adding a sleep dimension to the EQ-5D. Research is required to explore the method of adding dimensions to existing descriptive systems of health. Key words: EQ-5D; add-on; sleep; health state valuation; QALYs. (Med Decis Making 2014;34:42–53)
TL;DR: Variations in reported utilities are associated with factors such as cancer stage, time to or from initial care, and utility measurement instrument and more research is needed to study why apparently similar patients report different quality of life.
Abstract: Objective. To perform a systematic review of utility weights for colorectal cancer (CRC) health states reported in the scientific literature and to determine the effects of disease factors, patient characteristics, and utility methods on utility values. Methods. We identified 26 articles written in English and published from January 1980 to January 2013, providing 351 unique utilities for CRC health states elicited from 6546 unique respondents. The CRC utility data were analyzed using linear mixed-effects models with CRC type, stage, time to or from initial care, utility measurement instrument, and administration method as independent variables. Results. In the base case model, the estimated utility for a patient with stage I to III CRC more than 1 year after surgery, rated using a self-administered time tradeoff instrument, was 0.90. Stage, time to or from initial care, and utility measurement instrument were associated with statistically significant utility differences ranging from −0.19 to 0.02. Utilit...
TL;DR: A survival model selection process algorithm is proposed to guide modelers’ choice of projective models for use in future appraisals and practical advice is presented on issues of importance when using data from clinical trials terminated without complete follow-up as a basis for survival extrapolation.
Abstract: A recent publication includes a review of survival extrapolation methods used in technology appraisals of treatments for advanced cancers. The author of the article also noted shortcomings and inconsistencies in the analytical methods used in appraisals. He then proposed a survival model selection process algorithm to guide modelers’ choice of projective models for use in future appraisals. This article examines the proposed algorithm and highlights various shortcomings that involve questionable assumptions, including researchers’ access to patient-level data, the relevance of proportional hazards modeling, and the appropriateness of standard probability functions for characterizing risk, which may mislead practitioners into employing biased structures for projecting limited data in decision models. An alternative paradigm is outlined. This paradigm is based on the primacy of the experimental data and adherence to the scientific method through hypothesis formulation and validation. Drawing on extensive ex...
TL;DR: Findings suggest that diagnostics in low prevalence settings (e.g., screening) may be considered more beneficial when risk preferences are taken into account, and that common utility functions imply risk vulnerability.
Abstract: Risk attitudes include risk aversion as well as higher-order risk preferences such as prudence and temperance. This article analyzes the effects of such preferences on medical test and treatment decisions, represented either by test and treatment thresholds or-when the test result is not given-by optimal cutoff values for diagnostic tests. For a risk-averse decision maker, effective treatment is a risk-reducing strategy since it prevents the low health outcome of forgoing treatment in the sick state. Compared with risk neutrality, risk aversion thus lowers both the test and the treatment threshold and decreases the optimal test cutoff value. Risk vulnerability, which combines risk aversion, prudence, and temperance, is relevant if there is a comorbidity risk: thresholds and optimal cutoff values decrease even more. Since common utility functions imply risk vulnerability, our findings suggest that diagnostics in low prevalence settings (e.g., screening) may be considered more beneficial when risk preferences are taken into account.
TL;DR: The authors investigated whether the presentation format of the baseline risk influences understanding of relative risk changes and the mediating role of people's numeracy skills, and found that communicating baseline risk in a frequency format facilitated correct understanding of a t...
Abstract: Background. Treatment benefits and harms are often communicated as relative risk reductions and increases, which are frequently misunderstood by doctors and patients. One suggestion for improving understanding of such risk information is to also communicate the baseline risk. We investigated 1) whether the presentation format of the baseline risk influences understanding of relative risk changes and 2) the mediating role of people’s numeracy skills. Method. We presented laypeople (N = 1234) with a hypothetical scenario about a treatment that decreased (Experiments 1a, 2a) or increased (Experiments 1b, 2b) the risk of heart disease. Baseline risk was provided as a percentage or a frequency. In a forced-choice paradigm, the participants’ task was to judge the risk in the treatment group given the relative risk reduction (or increase) and the baseline risk. Numeracy was assessed using the Lipkus 11-item scale. Results. Communicating baseline risk in a frequency format facilitated correct understanding of a t...
TL;DR: The Health and Work Performance Questionnaire–based measure of presenteeism across occupations and industries is validated and Transforming responses by perceived performance of peers is unnecessary as absolute presenteeist correlated best with health indicators.
Abstract: Background. Illness-related presenteeism (suboptimal work performance) may be a significant factor in worker productivity. Until now, there has been no generally accepted best method of measuring presenteeism across different industries and occupations. This study sought to validate the Health and Work Performance Questionnaire (HPQ)-based measure of presenteeism across occupations and industries and assess the most appropriate method for data analysis. Methods. Work performance was measured using the modified version of the HPQ conducted in workforce samples from the education and health workforce in Queensland, Australia (N = 30,870) during 2005 and 2006. Three approaches to data analysis of presenteeism measures were assessed using absolute performance, the ratio of own performance to others' performance, and the difference between others' and own performance. The best measure is judged by its sensitivity to changes in health indicators. Results. The measure that best correlated to health indicators was absolute presenteeism. For example, in the health sector, correlations between physical health status and absolute presenteeism were 4 to 5 times greater than the ratio or difference approaches, and in the education sector, these correlations were twice as large. Using this approach, the estimated cost of presenteeism in 2006 was $Aus8338 and $Aus8092 per worker per annum for the health and education sectors, respectively. Conclusions. The HPQ is a valid measure of presenteeism. Transforming responses by perceived performance of peers is unnecessary as absolute presenteeism correlated best with health indicators. Absolute presenteeism was more insightful for ascertaining the cost of presenteeism.
TL;DR: This study provides reassurance that many criteria routinely used for technology decision making are considered to be relevant by the public and clearly indicate the perceived importance of prevention and early diagnosis.
Abstract: Background. Ethical, economic, political, and legitimacy arguments support the consideration of public preferences in health technology decision making. The objective was to assess public preferences for funding new health technologies and to compare a profile case best-worst scaling (BWS) and traditional discrete choice experiment (DCE) method. Methods. An online survey consisting of a DCE and BWS task was completed by 930 adults recruited via an Internet panel. Respondents traded between 7 technology attributes. Participation quotas broadly reflected the population of Queensland, Australia, by gender and age. Choice data were analyzed using a generalized multinomial logit model. Results. The findings from both the BWS and DCE were generally consistent in that respondents exhibited stronger preferences for technologies offering prevention or early diagnosis over other benefit types. Respondents also prioritized technologies that benefit younger people, larger numbers of people, those in rural areas, or indigenous Australians; that provide value for money; that have no available alternative; or that upgrade an existing technology. However, the relative preference weights and consequent preference orderings differed between the DCE and BWS models. Further, poor correlation between the DCE and BWS weights was observed. While only a minority of respondents reported difficulty completing either task (22.2% DCE, 31.9% BWS), the majority (72.6%) preferred the DCE over BWS task. Conclusions. This study provides reassurance that many criteria routinely used for technology decision making are considered to be relevant by the public. The findings clearly indicate the perceived importance of prevention and early diagnosis. The dissimilarity observed between DCE and profile case BWS weights is contrary to the findings of previous comparisons and raises uncertainty regarding the comparative merits of these stated preference methods in a priority-setting context.
TL;DR: Accurate ECG interpretation appears dependent on the perceptual skill of pattern recognition and specifically the time to fixate the critical lead(s), therefore, there is potential clinical utility in developing perceptual training programs to train novices to detect abnormalities more effectively.
Abstract: Background: The primary aim of this study is to understand more about the perceptual-cognitive mechanisms underpinning the expert advantage in electrocardiogram (ECG) interpretation. While research has examined visual search processes in other aspects of medical decision making (e.g., radiology), this is the first study to apply the paradigm to ECG interpretation. The secondary aim is to explore the role that clinical history plays in influencing visual search behavior and diagnostic decision making. While clinical history may aid diagnostic decision making, it may also bias the visual search process. Methods: Ten final-year medical students and 10 consultant emergency medics were presented with 16 ECG traces (8 with clinical history that was not manipulated independently of case) while wearing eye tracking equipment. The ECGs represented common abnormalities encountered in emergency departments and were among those taught to final-year medical students. Participants were asked to make a diagnosis on each...
TL;DR: The instrument developed to assess trauma triage decision making performed reliably and detected known group differences, however, it did not predict individual physician performance.
Abstract: Background. The evidence supporting the use of vignettes to study physician decision making comes primarily from the study of low-risk decisions and the demonstration of good agreement at the group...
TL;DR: People with the lowest levels of education had greater difficulties making an informed choice about participation in bowel screening and alternative methods are needed to support informed decision making among lower education populations.
Abstract: Background. Making informed decisions about cancer screening involves understanding the benefits and harms in conjunction with personal values. There is little research examining factors associated...
TL;DR: In this simulation study of 2 AMCs, hospital-based physicians had different perceptions of an identical case, hypothesize that different advance care planning norms may have influenced their decision-making heuristics.
Abstract: Background. There is wide variation in end-of-life (EOL) intensive care unit (ICU) use among academic medical centers (AMCs). Our objective was to develop hypotheses regarding medical decision-making factors underlying this variation. Methods. This was a high-fidelity simulation experiment involving a critically and terminally ill elder, followed by a survey and debriefing cognitive interview and evaluated using triangulated quantitative-qualitative comparative analysis. The study was conducted in 2 AMCs in the same state and health care system with disparate EOL ICU use. Subjects were hospital-based physicians responsible for ICU admission decisions. Measurements included treatment plan, prognosis, diagnosis, qualitative case perceptions, and clinical reasoning. Results. Sixty-seven of 111 (60%) eligible physicians agreed to participate; 48 (72%) could be scheduled. There were no significant between-AMC differences in 3-month prognosis or treatment plan, but there were systematic differences in perceptio...
TL;DR: The study improves the understanding of how individual inpatient discharge decisions can be objectively viewed in terms of their impact on other operations, such as ED crowding and readmission, in an acute care hospital.
Abstract: Background. When to discharge acute care patients is a complex decision that depends on both patient- and system-level factors. Such a decision for one patient affects other patients and operations in a hospital. The key tradeoff that we analyzed was the effect of discharge timing on several emergency department (ED)-related measures and the number of readmissions. Methods. We developed a discrete-event simulation model of patient pathway through an acute care hospital that comprises an ED and several inpatient units. The effects of discharge timing on ED waiting and boarding times, ambulance diversions, leave without treatment, and readmissions were explicitly modeled. We then analyzed the impact of 1 static and 2 proactive discharge strategies on these system outcomes. Results. Our analysis indicated that although the 2 proactive discharge strategies significantly reduced ED waiting and boarding times, and several other measures, compared with the static strategy (P < 0.01), the number of readmissions i...
TL;DR: A method for analyzing physician-patient interactions to ascertain whether decision making is patient centered can be assessed with high interrater agreement using a protocol that examines whether essential contextual information is addressed in the plan of care.
Abstract: Background and Objective. Adapting best evidence to the care of the individual patient has been characterized as “contextualizing care” or “patient-centered decision making” (PCDM). PCDM incorporates clinically relevant, patient-specific circumstances and behaviors, that is, the patient’s context, into formulating a contextually appropriate plan of care. The objective was to develop a method for analyzing physician-patient interactions to ascertain whether decision making is patient centered. Methods. Patients carried concealed audio recorders during encounters with their physicians. Recordings and medical records were reviewed for clues that contextual factors, such as an inability to pay for a medication or competing responsibilities, might undermine an otherwise appropriate care plan, rendering it ineffective. Iteratively, the team refined a coding process to achieve high interrater agreement in determining (a) whether the clinician explored the clues—termed “contextual red flags”—for possible underlyi...
TL;DR: Results indicate that defaults for low-impact items on electronic templates warrant careful attention because physicians are unlikely to override them, and this pattern suggests that physicians cognitively override incorrect default choices but only to a point.
Abstract: Background. American health care is transitioning to electronic physician ordering. These computerized systems are unique because they allow custom order interfaces. Although these systems provide ...
TL;DR: A negative correlation between age and maximizing was found: Physicians who were more advanced in their careers were less willing to spend time and effort in an exhaustive search for solutions, however, they appeared to have maintained their “mindware” for effective problem solving.
Abstract: Background. Patient outcomes critically depend on accuracy of physicians’ judgment, yet little is known about individual differences in cognitive styles that underlie physicians’ judgments. The obj...