A demographic study of campus activism at the University of Kansas

Honors thesi

Incorporating clinical guidelines through clinician decision-making

<p>Abstract</p> <p>Background</p> <p>It is generally acknowledged that a disparity between knowledge and its implementation is adversely affecting quality of care. An example commonly cited is the failure of clinicians to follow clinical guidelines. A guiding assumption of this view is that adherence should be gauged by a standard of conformance. At least some guideline developers dispute this assumption and claim that their efforts are intended to inform and assist clinical practice, not to function as standards of performance. However, their ability to assist and inform will remain limited until an alternative to the conformance criterion is proposed that gauges how evidence-based guidelines are incorporated into clinical decisions.</p> <p>Methods</p> <p>The proposed investigation has two specific aims to identify the processes that affect decisions about incorporating clinical guidelines, and then to develop ad test a strategy that promotes the utilization of evidence-based practices. This paper focuses on the first aim. It presents the rationale, introduces the clinical paradigm of treatment-resistant schizophrenia, and discusses an exemplar of clinician non-conformance to a clinical guideline. A modification of the original study is proposed that targets psychiatric trainees and draws on a cognitively rich theory of decision-making to formulate hypotheses about how the guideline is incorporated into treatment decisions. Twenty volunteer subjects recruited from an accredited psychiatry training program will respond to sixty-four vignettes that represent a fully crossed 2 × 2 × 2 × 4 within-subjects design. The variables consist of criteria contained in the clinical guideline and other relevant factors. Subjects will also respond to a subset of eight vignettes that assesses their overall impression of the guideline. Generalization estimating equation models will be used to test the study's principal hypothesis and perform secondary analyses.</p> <p>Implications</p> <p>The original design of phase two of the proposed investigation will be changed in recognition of newly published literature on the relative effectiveness of treatments for schizophrenia. It is suggested that this literature supports the notion that guidelines serve a valuable function as decision tools, and substantiates the importance of decision-making as the means by which general principles are incorporated into clinical practice.</p

Image Theory's counting rule in clinical decision making: Does it describe how clinicians make patient-specific forecasts?

The field of clinical decision making is polarized by two predominate views. One holds that treatment recommendations should conform with guidelines; the other emphasizes clinical expertise in reaching case-specific judgments. Previous work developed a test for a proposed alternative, that clinical judgment should systematically incorporate both general knowledge and patient-specific information. The test was derived from image theory's two phase-account of decision making and its ``simple counting rule'', which describes how possible courses of action are pre-screened for compatibility with standards and values. The current paper applies this rule to clinical forecasting, where practitioners indicate how likely a specific patient will respond favorably to a recommended treatment. Psychiatric trainees evaluated eight case vignettes that exhibited from 0 to 3 incompatible attributes. They made two forecasts, one based on a guideline recommendation, the other based on their own alternative. Both forecasts were predicted by equally- and unequally-weighted counting rules. Unequal weighting provided a better fit and exhibited a clearer rejection threshold, or point at which forecasts are not diminished by additional incompatibilities. The hypothesis that missing information is treated as an incompatibility was not confirmed. There was evidence that the rejection threshold was influenced by clinician preference. Results suggests that guidelines may have a de-biasing influence on clinical judgment. Subject to limitations pertaining to the subject sample and population, clinical paradigm, guideline, and study procedure, the data support the use of a compatibility test to describe how clinicians make patient-specific forecasts

Mental Illness, Violence Risk, and Race in Juvenile Detention: Implications for Disproportionate Minority Contact

Disproportionate minority contact (DMC) is a pervasive problem throughout the juvenile justice system. This article explored whether mental illness may be an explanatory factor in DMC. Data such as measures of violence risk and symptoms of mental illness were taken from intake interviews with 482 detained youth in Connecticut. Results indicated that racial minorities in detention have significantly lower violence risk than Caucasians but are disproportionately represented among detention populations relative to their proportions in the general population. In addition, DMC in these data was not explained by mental illness, seriousness of charges, violence risk, age, or gender. We suggest that mandated efforts to reduce DMC will need to address more than improving behavior or reducing symptoms of mental illness among detained minority youth. Instead, efforts should be focused on reducing the racial disparity evident in decisions made within the juvenile justice system