James G. Dolan

Randomized controlled trial of a patient decision aid for colorectal cancer screening

Purpose . To conduct a pilot test of a decision aid designed to help patients choose among currently recommended colorectal cancer screening programs. Methods . Randomized controlled trial comparing a patient decision aid based on multicriteria decision-making theory with a simple educational intervention. Patient population . 96 patients at average risk for colorectal cancer seen in an Internal Medicine practice in Rochester, New York. Outcome measures . The two primary outcome measures were patient decision process and the decision outcome. Patient decision process was assessed using the decisional conflict scale. Decision outcome was defined as the proportion of colorectal cancer screening plans carried out. Results . After controlling for the effects of the physicians in a factorial analysis of variance, patients who used the decision aid had lower decisional conflict regarding colorectal cancer screening decisions (F ratio6.47, P = 0.01) due to increased knowledge, better clarity of values, and higher ratings of the quality of the decisions they made. There was no difference between the groups in decision outcomes: 52% of patients in the control group and 49% in the experimental group completed planned screening tests (P = 1.0). Conclusions . In a pilot study, a multicriteria-based patient decision aid for colorectal cancer screening improved patients’ decision-making processes but had no effect on the implementation of screening plans.

Multi-criteria clinical decision support: A primer on the use of multiple criteria decision making methods to promote evidence-based, patient-centered healthcare

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 in the decision-making process, and actively involve both patients and healthcare 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 article 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.

The Analytic Hierarchy Process in Medical Decision Making A Tutorial

The analytic hierarchy process (AHP) is a quantitative decision making technique created es pecially for complicated, multicriteria decision problems. This report reviews the theoretical foundations of the AHP and shows how to use it in a step-by-step fashion.

Shared decision-making - transferring research into practice: The Analytic Hierarchy Process (AHP)

OBJECTIVE To illustrate how the Analytic Hierarchy Process (AHP) can be used to promote shared decision-making and enhance clinician-patient communication. METHODS Tutorial review. RESULTS The AHP promotes shared decision-making by creating a framework that is used to define the decision, summarize the information available, prioritize information needs, elicit preferences and values, and foster meaningful communication among decision stakeholders. CONCLUSIONS The AHP and related multi-criteria methods have the potential for improving the quality of clinical decisions and overcoming current barriers to implementing shared decision-making in busy clinical settings. Further research is needed to determine the best way to implement these tools and to determine their effectiveness. PRACTICE IMPLICATIONS Many clinical decisions involve preference-based trade-offs between competing risks and benefits. The AHP is a well-developed method that provides a practical approach for improving patient-provider communication, clinical decision-making, and the quality of patient care in these situations.

Medical Decision Making Using the Analytic Hierarchy Process: Choice of Initial Antimicrobial Therapy for Acute Pyelonephritis

The analytic hierarchy process (AHP) was used to determine which of seven recommended antibiotic regimens represented optimal initial therapy for a young woman hospitalized for treat ment of acute pyelonephritis. The model included the following criteria: maximize cure, minimize adverse effects (broken down into very serious, serious, and limited), minimize antibiotic resis tance, and minimize cost (divided into total cost and patient cost). The criteria were weighted according to judgments made by 61 practicing clinicians. Alternatives were compared relative to the criteria using published information on the expected frequencies of urinary pathogens and drug toxicity, local antibiotic sensitivities and antibiotic charges, and expert opinion regarding their propensities for inducing antimicrobial resistance. The analysis identified ampicillin com bined with gentamicin as the optimal regimen. This study illustrates several features of the AHP that make it promising for use in medical decision making: its ability to incorporate multiple criteria into a formal decision model, its procedural simplicity, and its similarity to current patient management guidelines. Further studies to establish the role of the AHP in medical decision making are warranted.

Optimal management of adults with pharyngitis – a multi-criteria decision analysis

BackgroundCurrent practice guidelines offer different management recommendations for adults presenting with a sore throat. The key issue is the extent to which the clinical likelihood of a Group A streptococcal infection should affect patient management decisions. To help resolve this issue, we conducted a multi-criteria decision analysis using the Analytic Hierarchy Process.MethodsWe defined optimal patient management using four criteria: 1) reduce symptom duration; 2) prevent infectious complications, local and systemic; 3) minimize antibiotic side effects, minor and anaphylaxis; and 4) achieve prudent use of antibiotics, avoiding both over-use and under-use. In our baseline analysis we assumed that all criteria and sub-criteria were equally important except minimizing anaphylactic side effects, which was judged very strongly more important than minimizing minor side effects. Management strategies included: a) No test, No treatment; b) Perform a rapid strep test and treat if positive; c) Perform a throat culture and treat if positive; d) Perform a rapid strep test and treat if positive; if negative obtain a throat culture and treat if positive; and e) treat without further tests. We defined four scenarios based on the likelihood of group A streptococcal infection using the Centor score, a well-validated clinical index. Published data were used to estimate the likelihoods of clinical outcomes and the test operating characteristics of the rapid strep test and throat culture for identifying group A streptococcal infections.ResultsUsing the baseline assumptions, no testing and no treatment is preferred for patients with Centor scores of 1; two strategies – culture and treat if positive and rapid strep with culture of negative results – are equally preferable for patients with Centor scores of 2; and rapid strep with culture of negative results is the best management strategy for patients with Centor scores 3 or 4. These results are sensitive to the priorities assigned to the decision criteria, especially avoiding over-use versus under-use of antibiotics, and the population prevalence of Group A streptococcal pharyngitis.ConclusionThe optimal clinical management of adults with sore throat depends on both the clinical probability of a group A streptococcal infection and clinical judgments that incorporate individual patient and practice circumstances.

A Method for Evaluating Health Care Providers' Decision Making The Provider Decision Process Assessment Instrument

Valid and reliable assessment of the clinical decision-making process is essential for the evaluation of decision aiding methods and effective quality assurance programs. The Provider Decision Process Assessment Instrument is a 12-item questionnaire that measures a health care providers degree of comfort with a medical decision. Its mea surement properties were studied in two general internal medicine practices. Reliability, measured using Cronbachs alpha, was 0.90 (95% CI = 0.87 to 0.92). Construct validity was also high, with expected negative correlations ranging from -0.53 to -0.67. The instrument also satisfied standard criteria for item homogeneity and was readily com pleted by clinicians. These results suggest that the Provider Decision Process As sessment Instrument will prove to be a valuable tool for assessing medical decision making in busy clinical settings. Key words: decision making; decision support sys tems ; quality assessment. (Med Decis Making 1999;19:38-41)

Patients’ preferences and priorities regarding colorectal cancer screening

Background. US colorectal cancer screening guidelines for people at average risk for colorectal cancer endorse multiple screening options and recommend that screening decisions reflect individual patient preferences. Methods. The authors used the analytic hierarchy process (AHP) to ascertain decision priorities of people at average risk for colorectal cancer attending primary care practices in Rochester, New York; Birmingham, Alabama; and Indianapolis, Indiana. The analysis included 4 decision criteria, 3 subcriteria, and 10 options. Results. Four hundred eighty-four people completed the study; 66% were female, 49% were African American, 9% had low literacy skills, and 27% had low numeracy skills. Overall, preventing cancer was given the highest priority (mean priority 55%), followed by avoiding screening test side effects (mean priority 17%), minimizing false-positive test results (mean priority 15%), and the combined priority of screening frequency, test preparation, and the test procedure(s) (mean priority 14%). Hierarchical cluster analysis revealed 6 distinct priority groupings containing multiple instances of decision priorities that differed from the average value by a factor of 4 or more. More than 90% of the study participants fully understood the concepts involved, 79% met AHP analysis quality standards, and 88% were willing to use similar methods to help make important health care decisions. Conclusion. These results highlight the need to facilitate incorporation of patient preferences into colorectal cancer screening decisions. The large number of study participants able and willing to perform the complex AHP analysis used for this study suggests that the AHP is a useful tool for identifying the patient-specific priorities needed to ensure that screening decisions appropriately reflect individual patient preferences.

Patient priorities in colorectal cancer screening decisions1

Background  Colorectal cancer screening guidelines in the United States recommend that decisions about screening should incorporate patient preferences, but little is known about how patients make the trade‐offs inherent in choosing one of the five currently recommended screening programmes.

Differences Between Dialysis Modality Selection and Initiation

BACKGROUND Although dialysis modality education is associated with higher rates of peritoneal dialysis (PD) use, some patients start hemodialysis (HD) therapy despite initially selecting PD as their modality of choice. This study seeks to identify predictors of this discrepancy. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS 217 patients who received dialysis modality education at the University of Rochester between January 2004 and September 2009 and subsequently started dialysis therapy. PREDICTORS Demographic (age, race, sex, and timing of education), social (education, income, insurance, marital, employment, and smoking status), and clinical data (estimated glomerular filtration rate, cause of end-stage renal disease [ESRD], number of comorbid conditions, and number of nephrology visits). OUTCOME HD use at initiation and day 91 of dialysis therapy in patients initially selecting PD. RESULTS Of 217 patients receiving education and starting dialysis therapy, at the time of education, 124 chose PD, 52 were undecided, and 41 chose HD. Modality distribution at the time of dialysis therapy initiation was 150 with HD and 67 with PD. Of 124 patients who chose PD at the time of education, 59 started dialysis therapy with PD and 65 started with HD. On day 91, a total of 60 patients were on PD therapy and 55 were on HD therapy. Nine patients had either died, undergone transplant, or not yet reached 91 days of dialysis therapy. On multivariable analysis, nonglomerular cause of ESRD, age older than 75 years, and not being employed predicted starting with HD therapy, whereas age older than 75 years, nonwhite race, and nonglomerular cause of ESRD predicted HD use at day 91. LIMITATIONS Single-center observational study. CONCLUSIONS This study shows that patients choosing PD after dialysis education may not start with this modality and identifies several predictors of this mismatch. Further investigation into predictors of this discrepancy and strategies promoting a PD start in patients selecting this modality are warranted.