High Stakes Decision Making: Normative, Descriptive and Prescriptive Considerations

This paper reviews the state of the art of research on individual decision-making in high-stakes, low-probability settings. A central theme of the discussion is that optimally resolving high-stakes decisions poses a formidable challenge not only to naïve decision makers, but also to users of more sophisticated tools such as decision analysis.. Such problems are difficult to resolve because precise information about probabilities is not available, and the dynamics of the decision are complex. When faced with such problems, naïve decision-makers fall prey to a wide range of potentially harmful biases, such as not recognizing a high-stakes problem, ignoring the information about probabilities that does exist, and responding to complexity by accepting the status quo. We offer an agenda for future research focusing on how the process and outcomes of high-stakes decision making might be improved

De rol van de vaktherapeut in ambulante ggz-behandelteams:Resultaten van het project ' (Be)Leef in de wijk'

Non-verbale, ervaringsgerichte behandelinterventies zoals vaktherapie zijn een belangrijk onderdeel van het behandelaanbod voor mensen met een lichte verstandelijke beperking (LVB) binnen de gespecialiseerde ggz-instellingen. In de praktijk valt op dat mensen met LVB en bijkomende problematiek binnen hun eigen leefomgeving nauwelijks een beroep kunnen doen op vaktherapie. En dat terwijl we in de zorg een verplaatsing zien van wonen in een instelling naar het blijven wonen in de wijk. Vaktherapeuten vragen zich af hoe ze mee kunnen bewegen in deze ontwikkelingen en hun aanbod meer in de leefomgeving van mensen met LVB kunnen laten plaatsvinden. Als antwoord op deze vraag is in het onderzoek ‘(Be)leef in de wijk’ een kader voor samenwerking ontwikkeld en geëvalueerd

Clinical Sequencing Exploratory Research Consortium: Accelerating Evidence-Based Practice of Genomic Medicine

Despite rapid technical progress and demonstrable effectiveness for some types of diagnosis and therapy, much remains to be learned about clinical genome and exome sequencing (CGES) and its role within the practice of medicine. The Clinical Sequencing Exploratory Research (CSER) consortium includes 18 extramural research projects, one National Human Genome Research Institute (NHGRI) intramural project, and a coordinating center funded by the NHGRI and National Cancer Institute. The consortium is exploring analytic and clinical validity and utility, as well as the ethical, legal, and social implications of sequencing via multidisciplinary approaches; it has thus far recruited 5,577 participants across a spectrum of symptomatic and healthy children and adults by utilizing both germline and cancer sequencing. The CSER consortium is analyzing data and creating publically available procedures and tools related to participant preferences and consent, variant classification, disclosure and management of primary and secondary findings, health outcomes, and integration with electronic health records. Future research directions will refine measures of clinical utility of CGES in both germline and somatic testing, evaluate the use of CGES for screening in healthy individuals, explore the penetrance of pathogenic variants through extensive phenotyping, reduce discordances in public databases of genes and variants, examine social and ethnic disparities in the provision of genomics services, explore regulatory issues, and estimate the value and downstream costs of sequencing. The CSER consortium has established a shared community of research sites by using diverse approaches to pursue the evidence-based development of best practices in genomic medicine

Omecamtiv mecarbil in chronic heart failure with reduced ejection fraction, GALACTIC‐HF: baseline characteristics and comparison with contemporary clinical trials

Aims: The safety and efficacy of the novel selective cardiac myosin activator, omecamtiv mecarbil, in patients with heart failure with reduced ejection fraction (HFrEF) is tested in the Global Approach to Lowering Adverse Cardiac outcomes Through Improving Contractility in Heart Failure (GALACTIC‐HF) trial. Here we describe the baseline characteristics of participants in GALACTIC‐HF and how these compare with other contemporary trials. Methods and Results: Adults with established HFrEF, New York Heart Association functional class (NYHA) ≥ II, EF ≤35%, elevated natriuretic peptides and either current hospitalization for HF or history of hospitalization/ emergency department visit for HF within a year were randomized to either placebo or omecamtiv mecarbil (pharmacokinetic‐guided dosing: 25, 37.5 or 50 mg bid). 8256 patients [male (79%), non‐white (22%), mean age 65 years] were enrolled with a mean EF 27%, ischemic etiology in 54%, NYHA II 53% and III/IV 47%, and median NT‐proBNP 1971 pg/mL. HF therapies at baseline were among the most effectively employed in contemporary HF trials. GALACTIC‐HF randomized patients representative of recent HF registries and trials with substantial numbers of patients also having characteristics understudied in previous trials including more from North America (n = 1386), enrolled as inpatients (n = 2084), systolic blood pressure < 100 mmHg (n = 1127), estimated glomerular filtration rate < 30 mL/min/1.73 m2 (n = 528), and treated with sacubitril‐valsartan at baseline (n = 1594). Conclusions: GALACTIC‐HF enrolled a well‐treated, high‐risk population from both inpatient and outpatient settings, which will provide a definitive evaluation of the efficacy and safety of this novel therapy, as well as informing its potential future implementation

How can we begin to measure recovery?

Abstract Background There is a lack of consensus in the addiction treatment literature regarding the definition of substance abuse "recovery". Methods This study utilized a review of the literature together with a participatory research design to construct a conceptual model of recovery from the perspectives of addiction treatment professionals, those recovering from addictions, and researchers. Results A multidimensional, comprehensive hypothetical model consisting of seven conceptual domains (physical, biomarker, psychological, psychiatric, chemical dependency, family/social, and spiritual) is presented. Each domain is operationally defined by identifying reliable and valid instruments that may be used to measure the domain. It is proposed that the conceptual model be tested using confirmatory factor analysis. Conclusions If empirically supported, this conceptual model would validate the hypothesized multidimensional nature of recovery and provide a potential means for assessing recovery in future treatment outcome studies.</p

Substance Abuse Treatment Modalities and Outcomes in a Naturalistic Setting

Outcome studies are gaining importance in all areas of medical, social services and education practices due to a growing emphasis on evidence-based interventions. Evidence-based programs and practices combine research evidence with clinical expertise; the ultimate goal is to optimize clinical outcomes and improve patient quality of life. The need to implement programs that have track records of effectiveness has never been greater. The specific research questions addressed by this study were: 1. Among patients who completed treatment, what are the abstinence rates at up to 3 months, 3-6 months, and 6-12 months post-discharge? 2. What are the effects of the various treatment modalities on inpatient treatment completion status? 3. How do demographic characteristics (age, gender, and diagnosis) affect treatment completion status? 4. Among patients who completed treatment, what are the effects of the various treatment modalities on abstinence at various points in time? 5. Among patients who completed treatment, how do demographic characteristics (age, gender, and diagnosis) affect abstinence? 6. By incorporating the significant results from questions 2-5, which factors remain significant in a final logistic regression model? A retrospective case series study based on chart review was conducted in a private residential substance abuse treatment facility. During the 18-month time period of the study, 775 patients entered treatment and 677 completed treatment (87.4%). For those who completed treatment, follow-up data were collected by telephone calls. The abstinence rate at one year, including non-respondents to follow-up, was approximately 11%. Women were less likely to be abstinent than men, even though they were more likely to complete treatment. Those aged 65+ and ≤ 30 were more likely to be abstinent than those aged 31-64, yet an incremental increase by age category was found to be associated with treatment completion. Two intervention modalities, relapse prevention and spirituality, significantly differentiated patients by treatment completion in a univariate analysis. In a multiple imputation logistic regression analysis of abstinence, social support was the only interventive modality found to be positively related to abstinence, OR=2.31 and 95% CI=(1.44, 3.68), while substance abuse counseling was the only modality found to be negatively associated with abstinence, OR=0.41 and 95% CI=(0.21, 0.82. Implications for treatment improvement are discussed

Prediction of bids for two-outcome gambles in a casino setting

An experimental game was conducted in a Las Vegas casino. Ninety two-outcome gambles were presented in turn, and the player's monetary evaluation of each gamble was determined by the Marschak bidding procedure. Ordinal tests supported the monotonicity and the cancellation properties that are necessary for any from the family of expectation models. A number of different parametric expectation models were tested by a least-squares method. The bids were well predicted by the expected value (EV) of the gambles. More elaborate predictors, in which parameters were estimated to represent the individual player's subjective probabilities and/or utilities, merely capitalized on noise; cross-validation showed that no real improvement could be obtained over the EV predictor. Furthermore, no single feature of the bet nor any linear combination of them did as well as EV.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/23451/1/0000402.pd