Paradoxical evidence weighting in confidence judgments for detection and discrimination

When making discrimination decisions between two stimulus categories, subjective confidence judgments are more positively affected by evidence in support of a decision than negatively affected by evidence against it. Recent theoretical proposals suggest that this "positive evidence bias" may be due to observers adopting a detection-like strategy when rating their confidence-one that has functional benefits for metacognition in real-world settings where detectability and discriminability often go hand in hand. However, it is unknown whether, or how, this evidence-weighting asymmetry affects detection decisions about the presence or absence of a stimulus. In four experiments, we first successfully replicate a positive evidence bias in discrimination confidence. We then show that detection decisions and confidence ratings paradoxically suffer from an opposite "negative evidence bias" to negatively weigh evidence even when it is optimal to assign it a positive weight. We show that the two effects are uncorrelated and discuss our findings in relation to models that account for a positive evidence bias as emerging from a confidence-specific heuristic, and alternative models where decision and confidence are generated by the same, Bayes-rational process

Video-Based Communication Assessment: Development of an Innovative System for Assessing Clinician-Patient Communication

Good clinician-patient communication is essential to provide quality health care and is key to patient-centered care. However, individuals and organizations seeking to improve in this area face significant challenges. A major barrier is the absence of an efficient system for assessing clinicians\u27 communication skills and providing meaningful, individual-level feedback. The purpose of this paper is to describe the design and creation of the Video-Based Communication Assessment (VCA), an innovative, flexible system for assessing and ultimately enhancing clinicians\u27 communication skills. We began by developing the VCA concept. Specifically, we determined that it should be convenient and efficient, accessible via computer, tablet, or smartphone; be case based, using video patient vignettes to which users respond as if speaking to the patient in the vignette; be flexible, allowing content to be tailored to the purpose of the assessment; allow incorporation of the patient\u27s voice by crowdsourcing ratings from analog patients; provide robust feedback including ratings, links to highly rated responses as examples, and learning points; and ultimately, have strong psychometric properties. We collected feedback on the concept and then proceeded to create the system. We identified several important research questions, which will be answered in subsequent studies. The VCA is a flexible, innovative system for assessing clinician-patient communication. It enables efficient sampling of clinicians\u27 communication skills, supports crowdsourced ratings of these spoken samples using analog patients, and offers multifaceted feedback reports

Dissemination of Evidence-based Atypical Antipsychotic Information to Nursing Homes

Background: Accumulating evidence demonstrates minimal benefit and increased risk of off-label use of atypical antipsychotic medications for dementia-related behaviors. Optimal strategy for disseminating evidence-based guides to nursing home (NH) stakeholders is unclear. Our objective is to describe the impact of differing dissemination efforts in Connecticut NHs. Methods: Forty-three Connecticut NHs were randomized to one of 3 arms receiving incrementally intensive dissemination strategies of the Agency for Healthcare Research and Quality Comparative Effectiveness Review Summary Guide on the off-label use of atypical antipsychotic drugs, which was included in a toolkit informed by a needs assessment of NHs. All NHs received the paper-based toolkit and notifications regarding the online toolkit. Additionally, Arm 2 received individualized quarterly audit and feedback reports with atypical antipsychotic prescribing rates; Arm 3 received in-person educational visits and audit and feedback reports. Toolkit reach was assessed using interviews with NH leadership and staff. Online toolkit use was assessed using Google analytics. Results: Eighty leaders and 222 direct care staff were interviewed. Leadership and direct care staff in Arm 3 NHs were more likely to be familiar with the toolkit that those in Arm 1 (p=0.008) and Arm 2 (p Conclusions: Intensive dissemination, using multi-pronged approach including academic detailing and direct care staff trainings, appeared to be associated with higher familiarity with paper-based toolkit, but not Internet-based use of the toolkit in the NH setting

Knowledge of and perceived need for evidence-based educational materials about antipsychotic medication safety by nursing home staff

Background: Given the widespread overuse of antipsychotic medications among US nursing home (NH) residents, we sought to identify knowledge of and perceived need for the AHRQ Comparative Effectiveness Research Summary Guide (CERSG) “Off-Label Use of Atypical Antipsychotic Drugs”. Methods: We conducted a baseline needs assessment with 12 NHs participating in a randomized controlled trail evaluating evidence dissemination strategies. Using a mixed method approach, we conducted in-depth assessments of knowledge, attitudes, and practice behavior using telephone interviews with NH leadership (administrators, directors of nursing [DON], and medical directors), and questionnaires with NH leadership, consultant pharmacists and direct care staff. Interviews were transcribed, verbatim responses were coded independently by 2 project staff. The coding scheme was revised after each round until substantial agreement (85%) was reached. Results: Interviews revealed that 70% of medical directors and 46% of DON and administrators believed that antipsychotics decreased agitation and controlled harmful behavior; 50% of medical directors and 7% of DONs & administrators reported knowledge of the increased risk of morbidity and mortality due to atypical antipsychotics. Half of administrators and DONs expressed interest in receiving information for NH staff pertaining to understanding dementia and dementia-related behaviors, 42% believed families would benefit from information about antipsychotic use for dementia-related behaviors. Questionnaire results were similar. When leaders were asked to list any risks associated with antipsychotic use for residents with dementia, only 17% reported death as a possible adverse event; licensed nursing staff (RN and LPNs) reported death 5% of the time. Over half of consultant pharmacists identified that their biggest barrier to improving medication use in challenging NHs was physician resistance to accepting recommendations. Conclusions: The responses of the NH leaders, staff and consultant pharmacists suggest widespread knowledge gaps regarding antipsychotic benefits and risks, and suggest a need for increase evidence dissemination and broad organizational change

Clinical considerations and key issues in the management of patients with Erdheim-Chester Disease: A seven case series

Background: Erdheim-Chester Disease (ECD), a non Langerhans' cell histiocytosis of orphan nature and propensity for multi-systemic presentations, comprises an intricate medical challenge in terms of diagnosis, treatment and complication management. Objectives: The objectives are to report the clinical, radiological and pathological characteristics, as well as cardinal therapeutic approaches to ECD patients and to provide clinical analyses of the medical chronicles of these complex patients. Methods: Patients with biopsy proven ECD were audited by a multi-disciplinary team of specialists who formed a coherent timeline of all the substantial clinical events in the evolution of their patients' illness. Results: Seven patients (five men, two women) were recruited to the study. The median age at presentation was 53 years (range: 39 to 62 years). The median follow-up time was 36 months (range: 1 to 72 months). Notable ECD involvement sites included the skeleton (seven), pituitary gland (seven), retroperitoneum (five), central nervous system (four), skin (four), lungs and pleura (four), orbits (three), heart and great vessels (three) and retinae (one). Prominent signs and symptoms were fever (seven), polyuria and polydipsia (six), ataxia and dysarthria (four), bone pain (four), exophthalmos (three), renovascular hypertension (one) and dyspnea (one). The V600E BRAF mutation was verified in three of six patients tested. Interferon-α treatment was beneficial in three of six patients treated. Vemurafenib yielded dramatic neurological improvement in a BRAF mutated patient. Infliximab facilitated pericardial effusion volume reduction. Cladribine improved cerebral blood flow originally compromised by perivenous lesions. Conclusions: ECD is a complex, multi-systemic, clonal entity coalescing both neoplastic and inflammatory elements and strongly dependent on impaired RAS/RAF/MEK/ERK signaling

A Mixed-Methods Study To Characterize Pharmaceutical Marketing in the Nursing Home Setting: Off-Label Use of Atypical Antipsychotics

Background: Despite FDA warnings that atypical antipsychotic medications are associated with an increased risk of death when used to treat behavioral disorders in older adults with dementia, they are prescribed to nearly one-third of older U.S. nursing home (NH) residents. Reasons for their high use in NHs are poorly understood, but may include pharmaceutical marketing efforts in the NH setting. Methods: This study is nested within an ongoing cluster randomized trial to improve the use of atypical antipsychotics in NHs. We analyzed semistructured interviews (n = 36) and surveys (n = 139) of administrators, directors of nursing and medical directors from 62 NHs in Connecticut. Using prescription drug claims from a national long-term care pharmacy, we arrayed study NHs into lowest to highest tertile of atypical antipsychotic use. We tested for differences in the receipt of information or clinical tools from pharmaceutical company representatives (PCRs) to manage dementia-related behaviors by medication use tertiles, adjusting for NH profit status, size, quality (overall, health inspections, staffing) and staffing measures (daily nurse hours per resident). Results: Average baseline use of atypical antipsychotics ranged from 6.6 to 44.3 percent of all residents in the facility. Approximately one-quarter of NH leaders presently receive information on dementia-related behavioral management strategies from PCRs through detailing, in-service training, written or Web-based material or sponsorship as speakers. However, we did not detect statistically significant differences in the receipt of information by level of atypical antipsychotic use, NH characteristics, quality and staffing measures. Conclusions: This first attempt to characterize pharmaceutical marketing within the NH setting did not find differences among reports of marketing efforts with respect to medication use and facility-level characteristics. However, studies across a wider geographic area should continue investigating the possible role of marketing efforts on overall use and choice of atypical antipsychotics in the NH setting

IDEAS for a healthy baby - reducing disparities in use of publicly reported quality data: study protocol for a randomized controlled trial

BACKGROUND: Publicly reported performance on quality measures is intended to enable patients to make more informed choices. Despite the growing availability of these reports, patients\u27 use remains limited and disparities exist. Low health literacy and numeracy are two barriers that may contribute to these disparities. Patient navigators have helped patients overcome barriers such as these in other areas, such as cancer care and may prove useful for overcoming barriers to using publicly reported quality data. METHODS/DESIGN: The goals of this study are: to determine the efficacy of a patient navigator intervention to assist low-income pregnant women in the use of publicly available information about quality of care when choosing a pediatrician; to evaluate the relative importance of factors influencing women\u27s choice of pediatric practices; to evaluate the effect of the intervention on patient engagement in management of their own and their child\u27s health care; and to assess variation in efficacy of the intervention for sub-groups based on parity, age, and race/ethnicity. English speaking women ages 16 to 50 attending a prenatal clinic at a large urban medical center will be randomized to receive an in-person navigator intervention or an informational pamphlet control between 20 to 34 weeks of gestation. The intervention will include in-person guided use of the Massachusetts Health Quality Partners website, which reports pediatric practices\u27 performance on quality measures and patient experience. The primary study outcomes will be the mean scores on a) clinical quality and b) patient experience measures. DISCUSSION: Successful completion of the study aims will yield important new knowledge about the value of guided website navigation as a strategy to increase the impact of publicly reported quality data and to reduce disparities in use of these data. TRIAL REGISTRATION: ClinicalTrials.gov #NCT01784575

Can we identify non-stationary dynamics of trial-to-trial variability?"

Identifying sources of the apparent variability in non-stationary scenarios is a fundamental problem in many biological data analysis settings. For instance, neurophysiological responses to the same task often vary from each repetition of the same experiment (trial) to the next. The origin and functional role of this observed variability is one of the fundamental questions in neuroscience. The nature of such trial-to-trial dynamics however remains largely elusive to current data analysis approaches. A range of strategies have been proposed in modalities such as electro-encephalography but gaining a fundamental insight into latent sources of trial-to-trial variability in neural recordings is still a major challenge. In this paper, we present a proof-of-concept study to the analysis of trial-to-trial variability dynamics founded on non-autonomous dynamical systems. At this initial stage, we evaluate the capacity of a simple statistic based on the behaviour of trajectories in classification settings, the trajectory coherence, in order to identify trial-to-trial dynamics. First, we derive the conditions leading to observable changes in datasets generated by a compact dynamical system (the Duffing equation). This canonical system plays the role of a ubiquitous model of non-stationary supervised classification problems. Second, we estimate the coherence of class-trajectories in empirically reconstructed space of system states. We show how this analysis can discern variations attributable to non-autonomous deterministic processes from stochastic fluctuations. The analyses are benchmarked using simulated and two different real datasets which have been shown to exhibit attractor dynamics. As an illustrative example, we focused on the analysis of the rat's frontal cortex ensemble dynamics during a decision-making task. Results suggest that, in line with recent hypotheses, rather than internal noise, it is the deterministic trend which most likely underlies the observed trial-to-trial variability. Thus, the empirical tool developed within this study potentially allows us to infer the source of variability in in-vivo neural recordings

On How Network Architecture Determines the Dominant Patterns of Spontaneous Neural Activity

In the absence of sensory stimulation, neocortical circuits display complex patterns of neural activity. These patterns are thought to reflect relevant properties of the network, including anatomical features like its modularity. It is also assumed that the synaptic connections of the network constrain the repertoire of emergent, spontaneous patterns. Although the link between network architecture and network activity has been extensively investigated in the last few years from different perspectives, our understanding of the relationship between the network connectivity and the structure of its spontaneous activity is still incomplete. Using a general mathematical model of neural dynamics we have studied the link between spontaneous activity and the underlying network architecture. In particular, here we show mathematically how the synaptic connections between neurons determine the repertoire of spatial patterns displayed in the spontaneous activity. To test our theoretical result, we have also used the model to simulate spontaneous activity of a neural network, whose architecture is inspired by the patchy organization of horizontal connections between cortical columns in the neocortex of primates and other mammals. The dominant spatial patterns of the spontaneous activity, calculated as its principal components, coincide remarkably well with those patterns predicted from the network connectivity using our theory. The equivalence between the concept of dominant pattern and the concept of attractor of the network dynamics is also demonstrated. This in turn suggests new ways of investigating encoding and storage capabilities of neural networks