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.     

An integrated framework for decision making in neurologic physical therapist practice

Decision-making frameworks are used by clinicians to guide patient management, communicate with other health care providers, and educate patients and their families. A number of frameworks have been applied to guide clinical practice, but none are comprehensive in terms of patient management. This article proposes a unifying framework for application to decision making in the management of individuals who have neurologic dysfunction. The framework integrates both enablement and disablement perspectives. The framework has the following attributes: (1) it is patient-centered, (2) it is anchored by the patient/client management model from the Guide for Physical Therapist Practice, (3) it incorporates the Hypothesis-Oriented Algorithm for Clinicians (HOAC) at every step, and (4) it proposes a systematic approach to task analysis for interpretation of movement dysfunction. This framework provides a mechanism for making clinical decisions, developing clinical hypotheses, and formulating a plan of care. Application of the framework is illustrated with a case example of an individual with neurologic dysfunction.     

Are we measuring what we need to measure?

Optimal treatment for patients with chronic pain remains elusive. A growing international consensus advocates evidence-based practice with assessment of clinical outcomes to improve the process and outcome of care. Clinical decision making about treatment options for an individual patient should include the patient's clinical presentation, available evidence, and patient preferences. Treatment should then be monitored and outcomes of treatment assessed. Although the placement of clinical decision making on a scientific, often quantitative basis as opposed to a subjective, impressionistic approach makes intuitive sense, the question is whether we have been measuring what we need to measure to practice evidence-based practice when we consider the current available evidence on pain management? The methods of synthesis of available evidence are still in development. Much of the evidence, although having internal validity, has limited external validity and is difficult to apply to the individual patient. Patients with chronic pain are a heterogeneous group, and different interventions may be indicated for different subgroups of patients. Various methods are being developed to better match patients with treatment. Little information exists on patient preferences, or how best to measure these. Information on how health care providers make clinical decisions is also scarce. Outcome measurement has come a long way and core domains to be measured have been established. Establishing normative data is a next main goal. Important methodologic and practical challenges remain to formulate evidence that can be applied to the individual patient with chronic pain.     

Building an evidence-based practice culture: incorporating evidence-based nursing in the clinical ladder system

Evidence-based practice has become a dominant trend in the healthcare with the objective of providing efficient, high quality health care, and policy making. Traditional problem-solving methods may not adequately address consumer needs in the rapidly changing modern healthcare system. In order to make correct decisions, a systematic and scientific approach to the collection, assessment, and interpretation of clinical information is essential for the health care provider. Creating an evidence-based practice nursing culture is the most fundamental way for nurses to recognize the importance of evidence-based nursing and, subsequently, adapt to solving clinical problems. This paper elaborates the strategy for incorporating evidence-based nursing into the clinical ladder system used at the authors' affiliated medical center. Three strategies are introduced. These are: (1) including the EBN concept in newcomer in-service training; (2) adopting evidence-based nursing practice competence as a criterion in the clinical ladder system, with various evidence-based, ladder-related reports required for promotion; and (3) providing support to nurses through centralized and decentralized education as well as individual consultation. The proposed strategy is provided as a practical reference for educators and policy makers working to foster evidence-based practice nursing cultures.     

A national survey of computerized decision support systems available to nurses in England

Aim  To examine the characteristics of computerized decision support systems (CDSS) currently available to nurses working in the National Health Service (NHS) in England.
Method  A questionnaire survey sent to a stratified random sample of 50% of all NHS care providers (Trusts) in England, asking respondents to provide information on CDSS currently used by nurses.
Results  Responses were received from 108 of the 277 Trusts included in the sample. Electronic patient record systems were the most common type of CDSS reported by Trusts ( n  = 61) but they were least likely to have features that have been associated with improved clinical outcomes.
Conclusions  The availability of CDSS with features that have been associated with improved patient outcomes for nurses in the NHS in England is limited. There is some evidence that the nature of the Trust affects whether or not nurses have access to CDSS to assist their decision making.
Implications for nursing management  The implementation of CDSS is increasing throughout the NHS. Many CDSS are introduced without adequate evidence to support its introduction and there is little evaluation of the benefits once they are implemented. Policy makers and nursing management should consider whether the introduction of CDSS aids nurse decision making and benefits patient outcomes.     

Outcomes benefit patients by helping nurses to incorporate proven therapies

Evidence-based medicine is the application of high-quality research findings to treatment decisions, utilizing practitioner expertise and taking into account patient variability and preference. Key elements necessary for successful evidence-based decision making are clinical guidelines and outcomes monitoring. Outcomes focus on measuring the result of actions taken, not on the processes used to obtain the result. Common outcomes monitors include survival, morbidity, patient satisfaction, and patient quality of life.     

End-of-Life Care in an Acute Care Hospital: Linking Policy and Practice

The care of people who die in hospitals is often suboptimal. Involving patients in decisions about their care is seen as one way to improve care outcomes. Federal and state government policymakers in Australia are promoting shared decision making in acute care hospitals as a means to improve the quality of end-of-life care. If policy is to be effective, health care professionals who provide hospital care will need to respond to its patient-centered purpose. Health services will also be called upon to train health care professionals to work with dying people in a more participatory way and to assist them to develop the clinical processes that support shared decision making. Health professionals who manage clinical workplaces become central in reshaping this practice environment by promoting patient-centered care policy objectives and restructuring health service systems to routinely incorporate patient and family preferences about care at key points in the patient's care episode.     

患者偏好与医患共同决策

循证医学提倡医务人员应用证据并考虑患者价值和偏好作出决策。医患共同决策基于医患双方均为"专家"的理念, 即医生作为医学专家提供医学专业意见, 而患者作为了解自身偏好的专家, 双方在充分讨论后共同作出医学决策。在此过程中, 医务人员应同时具备获取最佳证据以及应用决策辅助系统实现医患共同决策的能力。本文通过比较不同医学决策模式, 讨论医患共同决策的理论与实践, 并列举与中国医疗环境相关的、医患共同决策可能面临的挑战与障碍因素, 以期为临床作出合理决策以及提高医疗服务质量提供借鉴。     

Clinical decision rules as tools for evidence-based nursing

Nursing practice is fraught with uncertainty and our patients do not always respond predictably to our interventions. Properly developed and tested Clinical Decision Rules (CDRs), a special type of decision support tool, help organize research evidence into standardized patient assessments and treatments, thereby increasing the probability of attaining the desired outcome and reducing uncertainty in practice. The purpose of this article is to examine CDRs as one kind of decision support tool that can be used to facilitate nursing decision making and evidence-based practice (EBP). CDRs differ from both treatment algorithms and clinical pathways in the ways they are developed and in their scope of applicability. CDRs are developed using strict methodological standards, with the goal that they function well when used by a variety of care providers, with various patient populations, and in different patient care settings.     

The decision making of heart failure specialist nurses in clinical practice

Aims and objectives. To explore decision processes and types of decisions made by heart failure specialist nurses. Background. Heart failure specialist nurses are key to the management of patients with heart failure in the community. In previous studies heart failure specialist nurses have reported difficulty in developing decision making skills. Cognitive continuum theory can be used to examine the relationship between decision tasks and the processes used by heart failure specialist nurses to make decisions. Design. A qualitative study using non‐participant observation and semi‐structured interviews. Methods.  Six heart failure specialist nurses were observed while they carried out consultations with three patients each (n = 18). Twelve heart failure specialist nurses were interviewed about their decision making in practice. Data were analysed using thematic content analysis. Results. Two areas of decision making were identified by heart failure specialist nurses as key; pharmacological management and managing patients in the palliative phase of their condition. Pharmacological management decisions involved the trading off of risks and benefits of titrating medication, with nurses using internalised guidelines to inform their practice. In contrast, nurses relied on support from other health care professionals when making decisions about a patient’s need for palliative care. Conclusions. Medication titration decisions have a mixture of intuition and analysis inducing features making them amenable to the use of decision tools. The timing of the need for palliative care is less predictable, suggesting an intuitive approach to decision making may be more appropriate. Relevance to clinical practice. There are several strategies that could be used to improve the match between the decisions that heart failure specialist nurses take and the decision processes they use. These include the development of more tailored decision support tools for medication titration decisions and the provision of structured decision aids for assessing patients’ need for palliative care.     

A nurse-driven system for improving patient quality outcomes

Improvements in nursing care are dependent on key decision makers receiving ongoing and reliable information about outcomes as well as the support of clinical care providers in making change. This article describes the work of one hospital to develop a reporting tool and provides examples of how timely and appropriate reporting of data, combined with a staff-driven improvement process, has resulted in positive nursing and patient outcomes. Recommendations for future improvements in the system and applications to other hospitals are provided.     

Decision analysis and the implementation of evidence-based medicine.

The evidence-based medicine movement has received enthusiastic endorsement from editors of major medical journals. Hardly anyone can disagree with the aim of helping clinicians to make judicious use of the best scientific evidence for decisions in patient care. Evidence-based medicine, however, because of its dependence on randomized trials, cannot be applied to all individuals seen in daily practice. Specifically, patients may differ in age, severity of illness, presence of comorbidity and myriad of other clinical nuances. In response to these limitations, decision analysis, a technique which allows to consider multiple health outcomes, such as the patient's preferences for different states of health, and to measure the consequences of many strategies for which randomized trials are not feasible, provides a rational means of allowing health professionals to move from finding evidence to implementing it. Such formal approach may reconcile evidence-based medicine with 'real life' and patient's preference. It should therefore be considered complementary to evidence-based medicine.     

Treatment preference and patient centered prostate cancer care: Design and rationale

Prostate cancer is a slow progressing cancer that affects millions of men in the US. Due to uncertainties in outcomes and treatment complications, it is important that patients engage in informed decision making to choose the “optimal treatment”. Patient centered care that encompasses informed decision-making can improve treatment choice and quality of care. Thus, assessing patient treatment preferences is critical for developing an effective decision support system. The objective of this patient-centered randomized clinical trial was to study the comparative effectiveness of a conjoint analysis intervention compared to usual care in improving subjective and objective outcomes in prostate cancer patients. We identified preferred attributes of alternative prostate cancer treatments that will aid in evaluating attributes of treatment options. In this two-phase study, in Phase 1 we used mixed methods to develop an adaptive conjoint task instrument. The conjoint task required the patients to trade-off attributes associated with treatments by assessing their relative importance. Phase 2 consisted of a randomized controlled trial of men with localized prostate cancer. We analyzed the effect of conjoint task intervention on the association between preferences, treatment and objective and subjective outcomes. Our conjoint task instrument can lead to a values-based patient-centered decision aid tool and help tailor treatment decision making to the values of prostate cancer patients. This will ultimately improve clinical decision making, clinical policy process, enhance patient centered care and improve prostate cancer outcomes.     

Finding common ground: patient-centeredness and evidence-based chronic illness care

Health outcomes for patients with major chronic illnesses depend on the appropriate use of proven pharmaceuticals and other therapeutic technologies, and effective self-management by patients. Effective chronic illness care then bases clinical decisions on the best, rigorous scientific evidence, or evidence-based medicine. Effective support for patient self-management includes efforts to increase patient participation in care and collaborative goal-setting and planning of treatment. These interventions appear somewhat consistent with recent conceptualizations of patient-centered care. The consistent delivery of proven therapies and information and support for self-management requires practice systems organized for that purpose. The Chronic Care Model is a compilation of those practice system changes shown to improve chronic care. This paper explores the concept of patient-centeredness and its relationship to the Chronic Care Model. We conclude that the Model is both evidence-based and patient-centered and that these can be properties of health systems, and not just of individual practitioners.     

Evidence-based policy and procedures: an algorithm for success

Evidence-based practice is defined as the use of current best evidence by clinicians when making patient care decisions. Barriers to an evidence-based practice are well identified in the literature and significantly impact the use of research findings in practice. A key feature of a practice environment that supports and promotes the use of best evidence is requiring clinical practice policies and procedures to be evidence-based. The authors describe the structure and process developed to facilitate evidence-based policies and the outcomes of the initiative.     

Outcomes research at the National Cancer Institute: measuring,understanding, and improving the outcomes of cancer care

What is the National Cancer Institute (NCI) doing to enhance the state of the science for measuring and understanding patient-centered outcomes of cancer care and to make this information useful for improved decision making? The NCI has a new focus on research that describes, interprets, and predicts the impact of various influences, especially interventions, on end points that matter to decision makers. The research includes end points such as survival, health-related quality of life, satisfaction and patient experience, and economic burden. To further this work, NCI supports and conducts research to (1) identify valid, reliable, responsive, and feasible end-point measures; (2) collect high-quality evidence about the impact of interventions on the end points of interest; (3) improve our understanding of the effects of other factors that shape this interaction; and (4) expand our capacity to translate research findings into information that is useful to patients, clinical policy makers, payers, regulators, standard setters, and providers of cancer care.     

Coronary care nurses' clinical decision making

Increasing acuity of hospitalized persons with cardiac disease places great demands on nurses’ decision-making abilities. Yet nursing lags in knowledge-based system development because of limited understanding about how nurses use knowledge to make decisions. The two research questions for this study were: how do the lines of reasoning used by experienced coronary care nurses compare with those used by new coronary care nurses in a representative sample of hypothetical patient cases, and are the predominant lines of reasoning used by coronary care nurses in hypothetical situations similar to those used for comparable situations in clinical practice? Line of reasoning was defined as a set of arguments in which knowledge is embedded within decision-making processes that lead to a conclusion. Sixteen subjects (eight experienced and eight new nurses) from coronary care and coronary step-down units in a large, private, teaching hospital in Minnesota, USA, were asked to think aloud while making clinical decisions about six hypothetical cases and comparable actual case. One finding was that most subjects in both groups used multiple lines of reasoning per case; but they used only one predominantly. This finding highlighted the non-linear nature of clinical decision making. Subjects used 25 predominant lines of reasoning, with intergroup differences on six of them. Where there were differences, experienced nurses used lines of reasoning of lower quality than did new subjects. The type variability in lines of reasoning suggested that multiple pathways should be in-corporated into knowledge-system design. One implication of the variability in subjects’ line of reasoning quality is that nurses at all levels of expertise are fallible and could benefit from decision support. The finding that subjects tended to use similar lines of reasoning for comparable hypothetical and actual cases was modest validation of subjects’ performance on hypothetical cases as representing their decision making in practice. Consequently, there was support for using simulations and case studies in teaching and studying clinical decision making.     

Home parenteral nutrition: an ethical decision making dilemma.

Ethics is a hot topic these days. Home health care providers need not be ethicists, however they do need to be able to identify problems quickly, and know how to address them. This paper explores the ethical issues arising from a narrative analysis involving an advanced cancer patient receiving Total Parenteral Nutrition (TPN) at home. It shows how complicated it is today to make nutrition support decisions that would have been customary less than 30 years ago. For and against arguments of TPN for advanced cancer patients are reviewed. Ethical positions adopted by the medical and nursing professions are explored and contrasted. The importance of patient autonomy, within a holistic notion of care, including decisions incorporating quality of life, are affirmed, providing a challenge to monitoring the status quo in approaches to decision making.     

Critical care nurses' decision making: sedation assessment and management in intensive care

Aims. This study was designed to examine the decision making processes that nurses use when assessing and managing sedation for a critically ill patient, specifically the attributes and concepts used to determine sedation needs and the influence of a sedation guideline on the decision making processes. Background. Sedation management forms an integral component of the care of critical care patients. Despite this, there is little understanding of how nurses make decisions regarding assessment and management of intensive care patients’ sedation requirements. Appropriate nursing assessment and management of sedation therapy is essential to quality patient care. Design. Observational study. Methods. Nurses providing sedation management for a critically ill patient were observed and asked to think aloud during two separate occasions for two hours of care. Follow‐up interviews were conducted to collect data from five expert critical care nurses pre‐ and postimplementation of a sedation guideline. Data from all sources were integrated, with data analysis identifying the type and number of attributes and concepts used to form decisions. Results. Attributes and concepts most frequently used related to sedation and sedatives, anxiety and agitation, pain and comfort and neurological status. On average each participant raised 48 attributes related to sedation assessment and management in the preintervention phase and 57 attributes postintervention. These attributes related to assessment (pre, 58%; post, 65%), physiology (pre, 10%; post, 9%) and treatment (pre, 31%; post, 26%) aspects of care. Conclusions. Decision making in this setting is highly complex, incorporating a wide range of attributes that concentrate primarily on assessment aspects of care. Relevance to clinical practice. Clinical guidelines should provide support for strategies known to positively influence practice. Further, the education of nurses to use such guidelines optimally must take into account the highly complex iterative process and wide range of data sources used to make decisions.