Decision analysis in evidence-based decision making

Many real world decisions have to be made on a limited evidence base, and clinical decisions are at best problematic. We explored some of the reasons why decision making in health care is so complex, and examined how decision analytic techniques might contribute to problem structuring and to implementation of evidence-based practice. We argued that decision analysis could, to some extent, overcome complexity of decision making by a clear structuring of the problem and a formal analysis of the implications of different decisions. Decision-analytic techniques can guide the management of individual patients or can be used to address policy questions about the use of treatment for groups of patients. However, decision analysis is not without its criticisms, e.g. problems are narrowly defined, replacing judgement and dehumanizing care, neglect of process utility and lack of primary data to develop decision analytic models. The development of evidence-based guidelines is a key component of the UK Government's quality strategy led by the National Institute for Clinical Excellence (NICE). However, the guidelines approach may lead to conflict when assessments of the effectiveness of interventions for individuals (whether or not supported by a formal decision analysis) conflict with the recommendations made by NICE for cost and clinical effectiveness for aggregate groups of patients. Decision analysis may or may not help with this but if guidelines are derived from a decision analysis, then the implications of patient preferences should be made clearer. However, decision analysis-derived guidelines will make general recommendations that may not be appropriate for all individuals. Nonetheless, decision analysis does make such implications explicit and propose that the guidelines should be supported by some mechanism for determining individual patient preferences. It will now need to consider whether some of NICE resources should be directed beyond evidence-based guidelines into decision analysis-derived guidelines and into decision analytical techniques to provide support for clinical and cost effective decision making within the patient-clinician encounter.     

Rational decision making in medicine: Implications for overuse and underuse

In spite of substantial spending and resource utilization, today's health care remains characterized by poor outcomes, largely due to overuse (overtesting/overtreatment) or underuse (undertesting/undertreatment) of health services. To a significant extent, this is a consequence of low‐quality decision making that appears to violate various rationality criteria. Such suboptimal decision making is considered a leading cause of death and is responsible for more than 80% of health expenses. In this paper, we address the issue of overuse or underuse of health care interventions from the perspective of rational choice theory. We show that what is considered rational under one decision theory may not be considered rational under a different theory. We posit that the questions and concerns regarding both underuse and overuse have to be addressed within a specific theoretical framework. The applicable rationality criterion, and thus the “appropriateness” of health care delivery choices, depends on theory selection that is appropriate to specific clinical situations. We provide a number of illustrations showing how the choice of theoretical framework influences both our policy and individual decision making. We also highlight the practical implications of our analysis for the current efforts to measure the quality of care and link such measurements to the financing of health care services.     

Overview and critique of judgement and decision making in health care: social and procedural dimensions

This paper presents an outline of the scope for the application of decision theory to health care. Firstly, the main approaches to and assumptions of decision theory are discussed. Secondly, health care decision making is reviewed. It is noted that decision theory can be applied to either the health care professional or to the lay person. Applications of decision theory to clinical practice, to the management of care and to resourcing are considered. Thirdly, some areas which would repay further research are identified. These include social processes in individual and group decision making, the temporal distribution of outcomes and the development of techniques capable of dealing with the complex and dynamic features of decisions. On the basis of the foregoing, some conclusions are drawn.     

The impact of economic information on medical decision making in primary care

BACKGROUND: Many general practitioners (GPs) are concerned about the increasing dominance of economic issues in major decisions about clinical care, and feel their opinions on economic matters have not been heard. It is unclear whether this information has any impact on everyday clinical practice in a primary care setting. AIM: To investigate GPs' perspectives on the use of economic information in medical decision making. DESIGN OF STUDY: Cross-sectional survey. SETTING: GP members of the West of Scotland Primary Care Research and Development Network (WestNet). METHODS: Questionnaire survey sent to GPs by post and by email. RESULTS: The overall response rate was 44%, favouring postal over email responses. All respondents indicated that economic information has previously influenced them and should be incorporated into their medical decision making. The most common source of this information was generated by local authorities such as health boards, primary care groups and local prescribing advisors--used by 80% of the respondents. However, publications, such as the British Journal of General Practice, locally produced newsletters and prescribing formularies, and feedback from the General Practice Administration System for Scotland, were used as sources of economic information by 20%, 27% and 33%, respectively. Published materials--in particular, locally specific information and summarized information in leaflet format--were favoured (54%) in comparison to verbally presented material. CONCLUSIONS: GPs believe that economic information should be incorporated in medical decision making. The need for precise and summarized information, produced locally, has been highlighted. Better understanding towards the type of economic evidence GPs find useful and comprehensible is required.     

Modernizing the British National Health Service (NHS) -- some ideological and policy considerations: a commentary and application

The modernization of the British National Health Service, discussed by Peter Bradshaw in his paper, is having profound effects on nursing and patient care. The aim of this paper is to engage with the debate he has initiated in order to demonstrate its importance to nursing. The focus will be on key elements of the policy process not addressed by Peter Bradshaw as his emphasis was mainly on ideological concerns, but which nonetheless warrant consideration. These include the increasingly important role of evidence in policy making, and the role of nurses in the policy process. To this end four main themes are explored. First, specific comment is made on some of the points raised by Peter Bradshaw, in the context of the available evidence; secondly the role of evidence in the formulation and evaluation of policy is discussed; thirdly the policy process and nursing is examined; finally some tentative suggestions are made concerning the actions nurses and nurse managers can take to become more active in the health policy arena. The intention is to use Peter Bradshaw's work as a point of departure in examining further, some of the issues he highlights and to contribute to the debate.     

The role of research evidence in pharmaceutical policy making: evidence when necessary but not necessarily evidence

The use of research evidence in policy making at the legislative and administrative levels would appear to be very selective. Focusing on pharmaceutical policy, this paper argues that research evidence is only one ingredient leading to a policy decision and that any examination of research transfer into policy must take into account the many other factors which impact on decision making. The paper describes the policy making process, barriers to the uptake of research evidence into policy and ways of improving research uptake into policy making. Examples are given from drug licensing, remuneration policies, post-marketing surveillance and product withdrawal from the market.     

Concept analysis of decision making

TOPIC: Client decision making in relation to health care. PURPOSE: To develop a conceptual analysis of client decision making regarding health care that represents the current state of the science in order to better understand how clients make decisions. SOURCES: Published literature. CONCLUSIONS: A model of client decision making is presented with implications for nursing. Defining attributes, antecedents, consequences, and empirical referents of decision making are developed and illustrated by case presentations.     

Evidentiary challenges to evidence-based medicine

The evidence-based medicine (EBM) movement has exerted a strong influence on contemporary medicine. It has been used to define the hierarchy of knowledge in clinical medicine by classifying clinical findings according to the perceived relevance and validity of the respective methodologies of studies from which evidence was collected. In the spectrum of theories of knowledge, EBM predominantly relies on findings obtained from population-derived clinical research. This reliance on knowledge obtained from population studies sharply contrasts with a physiologic model of clinical knowledge advocated by basic science researchers and many clinicians. An apparent schism between proponents of physiologic and population models in the approach to the practice of medicine has been created. This dichotomy between practising physicians and EBM physicians in the approach to clinical knowledge should not be irreconcilable. We advocate a consilient approach to the interpretation of evidence and the integration of medical knowledge. This approach relies on 'linking of facts and fact-based theory across various disciplines to create a common groundwork of explanation'.     

Continuing professional development for interprofessional teams supporting patients in healthcare decision making

Healthcare professionals and organizations, policy makers, and the public are calling for safe and effective care that is centered on patients’ needs, values, and preferences. The goals of interprofessional shared decision making and decision support are to help patients and professionals agree on choices that are effective, health promoting, realistic, and consonant with patients’ and professionals’ values and preferences. This requires collaboration among professionals and with patients and their family caregivers. Continuing professional development is urgently needed to help healthcare professionals acquire the knowledge, skills, and attitudes necessary to create and sustain a culture of collaboration. We describe a model that can be used to design, implement, and evaluate continuing education curricula in interprofessional shared decision making and decision support. This model aligns curricular goals, objectives, educational strategies, and evaluation instruments and strategies with desired learning and organizational outcomes. Educational leaders and researchers can institutionalize such curricula by linking them with quality improvement and patient safety initiatives.     

Shared decision making: A dual‐layer model to tackling multimorbidity in primary care

It is common for primary care providers (PCPs) to manage complex multimorbidity. When caring for patients with multimorbidity, PCPs face challenges to tackle several issues within a short consultation in order to address patients' complex needs. Furthermore, some PCPs may lack access to a multidisciplinary team and need to manage multimorbidity within the confine of a PCP‐patient partnership only. Instead of attempting to address multiple health issues within a single consultation, it would be more feasible and time effective for PCPs and patients to jointly prioritize the health issue to focus on. Using the Malaysian primary care setting as a case study, a dual‐layer‐shared decision‐making approach is proposed whereby PCPs and patients make decisions on which disease(s) (layer 1) and treatment(s) (layer 2) to prioritize. This dual‐layer model aims to address the challenges of short consultation time and limited healthcare resources by encouraging PCPs and patients to discuss, negotiate, and agree on the decision during the consultation to ensure patients' health needs are addressed.     

The application of decision making concepts by nurse practitioners in general practice

The application of decision making concepts by nurse practitioners in general practice ¶This paper is concerned with the conceptual frameworks which could be applied to nurse practitioners in general practice in reaching decisions during patient consultations. Four strategies of decision making are explained within a practice context: hypothetico-deductive method, decision analysis, pattern recognition and intuition. The study uses retrospective verbalization and observation of 20 nurse practitioners working alongside general practitioners to explore decision making issues. The results of the study show that important factors relating to decision making include: the ability to recognize patterns in clinical situations to fit with patterns previously seen; an appreciation of the consequences of inappropriate action; and the ability to concentrate simultaneously on complex and sometimes masked patient cues as well as multiple treatment options.     

Classifying clinical decision making: a unifying approach

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

Professionals' perceptions of children's participation in decision making in healthcare

The purpose of this study was to identify factors of importance for children's participation in medical and nursing care. A method close to the critical incident technique was used. A total of 92 stories told by staff and containing different levels of children's participation in decision making were analysed. The factors affecting children's participation in decision making were grouped into six categories: the child's protest, the child's age and maturity, the role of parents, attitudes of staff, the time factor and alternative solutions to the problem. This study shows that in certain cases children can affect their situation, bus also that violating actions are performed on children.