Extending remote patient monitoring with mobile real time clinical decision support

Large scale implementation of telemedicine services such as telemonitoring and teletreatment will generate huge amounts of clinical data. Even small amounts of data from continuous patient monitoring cannot be scrutinised in real time and round the clock by health professionals. In future huge volumes of such data will have to be routinely screened by intelligent software systems. We investigate how to make m-health systems for ambulatory care more intelligent by applying a Decision Support approach in the analysis and interpretation of biosignal data and to support adherence to evidence-based best practice such as is expressed in treatment protocols and clinical practice guidelines. The resulting Clinical Decision Support Systems must be able to accept and interpret real time streaming biosignals and context data as well as the patient’s (relatively less dynamic) clinical and administrative data. In this position paper we describe the telemonitoring/teletreatment system developed at the University of Twente, based on Body Area Network (BAN) technology, and present our vision of how BAN-based telemedicine services can be enhanced by incorporating mobile real time Clinical Decision Support. We believe that the main innovative aspects of the vision relate to the implementation of decision support on a mobile platform; incorporation of real time input and analysis of streaming\ud biosignals into the inferencing process; implementation of decision support in a distributed system; and the consequent challenges such as maintenance of consistency of knowledge, state and beliefs across a distributed environment

FuelWatch: evidence-based-policy or policy based evidence?

Experience from the United Kingdom and the United States suggests that expert evidence is often reshaped and repackaged by governments so that it supports existing policy rather than informing policy decisions. The Australian government based its decision to introduce FuelWatch on evidence in the form of econometric work by the ACCC. This paper asks two questions about that decision. First, was the policy shaped by the economet- ric evidence or was the government�s presentation of the evidence shaped by the pre-determined policy? Second, is the econometric evidence sufficiently robust as to support the FuelWatch policy? I find that some of the facts suggest that evidence was reshaped and repackaged to support the FuelWatch policy. I also find that the ACCC analysis was not robust. Specifically, they study the nominal retail margin when economic theory suggests that analysis should focus on the real retail margin to producers. Using data digitized from a graph in the ACCC report I redo the econometric analysis and find that the evidence no longer unambiguously supports the FuelWatch policy. The ACCC claim that their analysis is robust because it has been subject to scrutiny within the ACCC and by Treasury but such claims of robustness cannot be verified because they refuse to release the data for public scrutiny. Publication of data and analysis underpinning government decisions and independent review of econometric work provides a more credible evidence base for future policy decisions.FuelWatch; Evidence-based policy; Petrol pricing;Time series econometrics; Structural breaks;Hypothesis testing; HACC standard errors

Applied and conceptual approaches to evidence-based practice in research and academic libraries

Evidence-based practice is an approach to professional practice that involves a structured process of collecting, interpreting and applying valid and reliable research and evidence to support decision-making and continuous service improvement in professional practice. This paper reports on emerging initiatives in evidence-based practice at the University of Southern Queensland (USQ) Library, a regional multi-campus university in Australia. It demonstrates how evidence-based practice forms part of our organisational strategy to engage with our community and society. The case study describes a new model of embedding evidence-based practice through a role explicitly dedicated to developing the library’s evidence base. While other libraries may have a person responsible for assessment, performance metrics or data analysis, the Coordinator (Evidence-Based Practice) has a broader mandate – to work with library staff to develop tools, skills and expertise in evidence-based practice. The paper will describe why this role was created and how the Coordinator is working to engage with library staff to understand their business and the evidence needed to support service improvement for the Library. By doing this, USQ Library is building the capacity to demonstrate value to stakeholders, gain a deeper understanding of clients’ needs and experiences, promote robust decision-making and improve service delivery. The paper also outlines an initiative led by the Coordinator (Evidence-Based Practice) to develop a conceptual model of evidence-based practice within academic libraries at the organisational, rather than individual level. Current models of evidence-based library and information practice apply predominantly to individuals. Informed by relevant literature and 16 semi-structured interviews with library professionals from Australian and New Zealand university libraries, three themes emerged to describe how evidence-based practice might be experienced at the organisational level. The lived experience at USQ Library and our research investigations suggest that being evidence-based provides benefits to an academic library’s culture, practice and impact

A state-of-the-art multi-criteria model for drug benefit-risk analysis

Drug benefit-risk analysis is based on firm clinical evidence related to various safety and efficacy outcomes, such as tolerability, treatment response, and adverse events. In this paper, we propose a new approach for constructing a supporting multi-criteria model that fully takes into account this evidence. Our approach is based on the Stochastic Multicriteria Acceptability Analysis (SMAA) methodology, which allows us to compute the typical value judgments that support a decision, to quantify uncertainty, and to compute a comprehensive benefit-risk profile. As an example, we constructed a multi-criteria model for the therapeutic group of second-generation antidepressants. We analyzed Fluoxetine, Paroxetine, Sertraline, and Venlafaxine according to relative efficacy and absolute rates of several common adverse drug reactions using meta-analytical data from the literature. Our model showed that there are clear trade-offs among the four drugs. Based on our experiences from this study, SMAA appears to be a suitable approach for quantifying trade-offs and decision uncertainty in drug benefit-risk analysis.

A prospective multiple case study of the impact of emerging scientific evidence on established colorectal cancer screening programs: a study protocol.

BackgroundHealth-policy decision making is a complex and dynamic process, for which strong evidentiary support is required. This includes scientifically produced research, as well as information that relates to the context in which the decision takes place. Unlike scientific evidence, this "contextual evidence" is highly variable and often includes information that is not scientifically produced, drawn from sources such as political judgement, program management experience and knowledge, or public values. As the policy decision-making process is variable and difficult to evaluate, it is often unclear how this heterogeneous evidence is identified and incorporated into "evidence-based policy" decisions. Population-based colorectal cancer screening poses an ideal context in which to examine these issues. In Canada, colorectal cancer screening programs have been established in several provinces over the past five years, based on the fecal occult blood test (FOBT) or the fecal immunochemical test. However, as these programs develop, new scientific evidence for screening continues to emerge. Recently published randomized controlled trials suggest that the use of flexible sigmoidoscopy for population-based screening may pose a greater reduction in mortality than the FOBT. This raises the important question of how policy makers will address this evidence, given that screening programs are being established or are already in place. This study will examine these issues prospectively and will focus on how policy makers monitor emerging scientific evidence and how both scientific and contextual evidence are identified and applied for decisions about health system improvement.MethodsThis study will employ a prospective multiple case study design, involving participants from Ontario, Alberta, Manitoba, Nova Scotia, and Quebec. In each province, data will be collected via document analysis and key informant interviews. Documents will include policy briefs, reports, meeting minutes, media releases, and correspondence. Interviews will be conducted in person with senior administrative leaders, government officials, screening experts, and high-level cancer system stakeholders.DiscussionThe proposed study comprises the third and final phase of an Emerging Team grant to address the challenges of health-policy decision making and colorectal cancer screening decisions in Canada. This study will contribute a unique prospective look at how policy makers address new, emerging scientific evidence in several different policy environments and at different stages of program planning and implementation. Findings will provide important insight into the various approaches that are or should be used to monitor emerging evidence, the relative importance of scientific versus contextual evidence for decision making, and the tools and processes that may be important to support challenging health-policy decisions

Evidence synthesis as the basis for decision analysis: a method of selecting the best agricultural practices for multiple ecosystem services

Agricultural management practices have impacts not only on crops and livestock, but also on soil, water, wildlife, and ecosystem services. Agricultural research provides evidence about these impacts, but it is unclear how this evidence should be used to make decisions. Two methods are widely used in decision making: evidence synthesis and decision analysis. However, a system of evidence-based decision making that integrates these two methods has not yet been established. Moreover, the standard methods of evidence synthesis have a narrow focus (e.g., the effects of one management practice), but the standard methods of decision analysis have a wide focus (e.g., the comparative effectiveness of multiple management practices). Thus, there is a mismatch between the outputs from evidence synthesis and the inputs that are needed for decision analysis. We show how evidence for a wide range of agricultural practices can be reviewed and summarized simultaneously (“subject-wide evidence synthesis”), and how this evidence can be assessed by experts and used for decision making (“multiple-criteria decision analysis”). We show how these methods could be used by The Nature Conservancy (TNC) in California to select the best management practices for multiple ecosystem services in Mediterranean-type farmland and rangeland, based on a subject-wide evidence synthesis that was published by Conservation Evidence (www.conservationevidence.com). This method of “evidence-based decision analysis” could be used at different scales, from the local scale (farmers deciding which practices to adopt) to the national or international scale (policy makers deciding which practices to support through agricultural subsidies or other payments for ecosystem services). We discuss the strengths and weaknesses of this method, and we suggest some general principles for improving evidence synthesis as the basis for multi-criteria decision analysis

Development and preliminary evaluation of a clinical guidance programme for the decision about prophylactic oophorectomy in women undergoing a hysterectomy

Objectives: To develop a decision analysis based and computerised clinical guidance programme (CGP) that provides patient specific guidance on the decision whether or not to undergo a prophylactic oophorectomy to reduce the risk of subsequent ovarian cancer and to undertake a preliminary pilot and evaluation. Subjects: Women who had already agreed to have a hysterectomy who otherwise had no ovarian pathology. Setting: Oophorectomy decision consultation at the outpatient or pre-admission clinic. Methods: A CGP was developed with advice from gynaecologists and patient groups, incorporating a set of Markov models within a decision analytical framework to evaluate the benefits of undergoing a prophylactic oophorectomy or not on the basis of quality adjusted life expectancy, life expectancy, and for varying durations of hormone replacement therapy. Sensitivity analysis and preliminary testing of the CGP were undertaken to compare its overall performance with established guidelines and practice. A small convenience sample of women invited to use the CGP were interviewed, the interviews were taped and transcribed, and a thematic analysis was undertaken. Results: The run time of the programme was 20 minutes, depending on the use of opt outs to default values. The CGP functioned well in preliminary testing. Women were able to use the programme and expressed overall satisfaction with it. Some had reservations about the computerised format and some were surprised at the specificity of the guidance given. Conclusions: A CGP can be developed for a complex healthcare decision. It can give evidence-based health guidance which can be adjusted to account for individual risk factors and reflects a patient’s own values and preferences concerning health outcomes. Future decision aids and support systems need to be developed and evaluated in a way which takes account of the variation in patients’ preferences for inclusion in the decision making process

Medical Data Architecture Prototype Development - Summary of Recent Work and Proposed Ideas for Upcoming Work

The Medical Data Architecture (MDA) project supports the Exploration Medical Capability (ExMC) risk to minimize or reduce the risk of adverse health outcomes and decrements in performance due to in-flight medical capabilities on human exploration missions. To mitigate this risk, the ExMC MDA project addresses the technical limitations identified in ExMC Gap Med 07: We do not have the capability to comprehensively process medically-relevant information to support medical operations during exploration missions, and in ExMC Gap Med 10: We do not have the capability to provide computed medical decision support during exploration missions. These gaps recognize the need for a comprehensive medical data management system and the accompanying computational support to provide autonomous medical care during long duration exploration missions. As the MDA maturesincluding the capability to comprehensively process and discover medically-relevant information to support medical operations during exploration missionsproject focus will shift to maturing and extending the MDA platform to enable clinical decision support and real-time guidance. To date, the MDA foundational architecture has recommended exploration medical system Level of Care IV requirements through a series of test bed prototype developments and analog demonstrations. The next stage in the development will focus on more autonomous clinical decision making necessary to address challenges in executing a self-contained medical system that enables health care both with and without assistance from ground support. A thorough understanding of current state of medical decision support systems, advanced machine learning algorithms and vast and varied data sources is required. The development of a clinical decision support for exploration missions (Level of Care V) roadmap is needed: one that assesses of current state of the art of clinical decision support systems (CDSS), interoperability issues, identification of challenges in health and performance monitoring, obtaining and processing information from biosensors, knowledge and data management, data integration and fusion, and advanced algorithm development. This roadmap must also include rapid prototype development in the areas of data processing, advanced analysis and prediction of medical events, and treatment based on medically relevant information processing and evidence-based best practices. In this presentation, an overview of the relevant issues and the beginning framework of a Level of Care V CDSS development roadmap will be provided

Decision Making Processes for Global Product Development - a Case Study

Global Product Development (GPD), outsourcing and offshoring of product development is a widespread phenomenon on today’s global economy, and consequently most engineering manufacturing companies will have to make decisions regarding how to organise their product development activities globally. This paper investigates decision making in the GPD context, partly by summarizing existing literatures and studies in the field, and partly through a case study of decision making processes in a global engineering company. Through interviews a range of GPD decisions were mapped and analysed in order to investigate how decisions are made and which information decisions are based on. The study found that decision making is not always structured, and that prioritised decision making is more dominant than planned decision making. The findings set the stage for further analysis of decision making in GPD, and for development of support tools decision support tools for manager, which are based on empirical evidence and experience

Using cost-effectiveness analyses to inform policy: the case of antiretroviral therapy in Thailand.

BACKGROUND: Much emphasis is put on providing evidence to assist policymakers in priority setting and investment decisions. Assessing the cost-effectiveness of interventions is one technique used by policymakers in their decisions around the allocation of scarce resources. However, even where such evidence is available, other considerations may also be taken into account, and even over-ride technical evidence. Antiretroviral therapy (ART) is the most effective intervention to reduce HIV-related morbidity and prolong mortality. However, treatment provision in the developing world has been hindered by the high costs of services and drugs, casting doubts on its cost-effectiveness. This paper looks at Thailand's publicly-funded antiretroviral initiative which was first introduced in 1992, and explores the extent to which cost-effectiveness evidence influenced policy. METHODS: This article reviews the development of the national ART programme in Thailand between 1992 and 2004. It examines the roles of cost-effectiveness information in treatment policy decisions. Qualitative approaches including document analysis and interview of key informants were employed. RESULTS: Two significant policy shifts have been observed in government-organised ART provision. In 1996, service-based therapy for a few was replaced by a research network to support clinical assessments of antiretroviral medication in public hospitals. This decision was taken after a domestic study illustrated the unaffordable fiscal burden and inefficient use of resources in provision of ART. The numbers of treatment recipients was maintained at 2,000 per year throughout the 1990s. It was not until 2001 that a new government pledged to extend the numbers receiving the service, as part of its commitment to universal coverage. Several elements played a role in this decision: new groups of dominant actors, drug price reductions, a pro-active civil society movement, lessons from experience on treatment benefits, and global treatment advocacy. Unlike previous policy discourse, human rights, ethics and equity notions were explicitly raised to support therapy extension. CONCLUSION: In the early decision, moving from a relatively limited ART service to a research network was clearly influenced by cost-effectiveness data. But in the 2001 decision to include ART in the universal coverage package, cost-effectiveness arguments were over-ruled by other considerations. Thai ART policy was shaped by many factors, and was not a simple rational process which relied on evidence