PST11 THE USE OF MULTI-CRITERIA DECISION METHODS IN HEALTH CARE. DOES METHOD USED INFLUENCE OUTCOME?

OBJECTIVES: To investigate how the choice of multicriteria decision method influences outcome (ranking criteria and criteria weights). Population. A convenience sample of 28 subjects, 12 healthy and 16 cognitively impaired. METHODS: Based on a literature review, 5 multicriteria methods were chosen for comparison including: Kepner-tregoe analysis (KTA), simple multi attribute rating technique (SMART), SMART using swing weights (SWING), Analytic Hierarchy Process (AHP) and Conjoint Analysis (CA). Four attributes of treatment were identified (impact, duration, and end-result of treatment and associated risks). Subjects were asked to both rank and rate the importance of these attributes with each method. The order of methods was randomized and the total length of the interview was restricted to one hour. Some subjects therefore did not use all methods. Subjects were interviewed either once (n = 14) or twice (n = 14) (Only the results of the first measurement are presented) RESULTS: The highest percentages of rank reversals were found between CA and other methods (55–62%). The lowest percentage of rank reversals was between KTA and SMART (18%). The percentage of rank reversals was significantly higher in impaired population (An average of 54% compared to 36% in unimpaired population). When comparing actual weights, AHP and SMART correlate highly with all other methods except CA. CONCLUSIONS: The high percentages in rank reversal and divergent correlation between individual weights (especially CA compared to other methods) show that the method chosen influences outcome. This has to be taken into account when the ranks or weights are used in multi-criteria decision analysis to make actual treatment decisions. The dissimilar methodology of CA might explain the high percentages of rank-reversals and low correlation between this method and other. Also, the design of the survey might have influenced CA weights and ranking

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

BACKGROUND: Current 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. METHODS: We 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. RESULTS: Using 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. CONCLUSION: The 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

Providing alternative measures for addressing adverse drug-drug interactions

First Online 30 March 2019Clinical Practice Guidelines (CPGs) are documents used in daily clinical practice that provide advice on how to best diagnose and treat diseases in the form of a list of clinical recommendations. When simultaneously applying multiple CPGs to patients, this can lead to complex multiple drug regimens (polypharmacy) with the potential for harmful combinations of drugs. The need to address these adverse drug events calls forth for systems capable of not only automatically represent the common potential conflicts or interactions that can happen when merging CPGs but also systems capable of providing conflict-free alternatives. This paper presents a solution that represents CPGs as Computer-Interpretable Guidelines (CIGs) and allows the automatic identification of drug conflicts and the provision of alternative measures to resolve these conflicts.This work has been supported by COMPETE: POCI-01-0145-FEDER-0070 43 and FCT – Fundação para a Ciência e Tecnologia within the Project Scope UID/CEC/ 00319/2013. The work of Tiago Oliveira was supported by JSPS KAKENHI Grant Number JP18K18115

Challenges and solutions for enhancing agriculture value chain decision-making. A short review

© IFIP International Federation for Information Processing 2017. Increasingly challenging global and environmental requirements have resulted in agricultural systems coming under increasing pressure to enhance their resilience capabilities. This in special to respond to the abrupt changes in resource quality, quantity and availability, especially during unexpected environmental circumstances, such as uncertain weather, pests and diseases, volatile market conditions and commodity prices. Therefore, integrated solutions are necessary to support the knowledge-management, collaborative ICT solution, risk management and regulation management across agriculture stakeholders. Therefore, and based on the on-going work under the H2020 RUC-APS project research network, this book chapter is oriented to contribute to agriculture value chain decision-making field to cover the current need on gathering a common understanding and appreciation of new trends in agriculture value chain, in special the multi-disciplinary challenges. For this, a short a literature review is conducted to summarise the main findings on real application and current research trends. This within the objective to propose an integrated framework based on better use of communication ways, standardised structures, development of training and awareness, regulation based initiatives and vertical Integration

Warm fjords and vegetated landscapes in early Pliocene East Antarctica

The response of the Antarctic ice sheets to future warming is uncertain. The IPCC are predicting minimal melt from Antarctica while others suggest increased meltwater contributions are possible. The Pliocene period (5.333 Ma to 2.58 Ma) may provide insights into future ice sheet response, because atmospheric CO2 concentrations were similar to today (350-450 ppmv) and the earth surface was between 2 °C and 4 °C warmer than the preindustrial conditions. Geological records indicate that Antarctica's ice sheets were smaller and more dynamic at this time and many sea-level estimates require meltwater input from the Greenland, West (WAIS) and East Antarctic Ice sheets (EAIS). However, only a few records exist proximal to the Antarctic ice sheet which allow for reconstruction of the Pliocene climate state. We present a multiproxy climate reconstruction from a sedimentary succession that was deposited in an ancient fjord within the Transantarctic Mountains, covering discrete intervals between the early Pliocene and the late Pleistocene. In contrast to modern frigid conditions, our records indicate sea surface temperatures of about 5.6 °C at c. 4.1 Ma, the presence of a plant community at the fjord margins and evidence of soil formation. Simulations of potential vegetation cover in the Pliocene indicate our reconstruction is most compatible with a complete collapse of the WAIS and a large scale retreat of the EAIS from the subglacial basins with atmospheric CO2 levels of less than 450 ppmv. Our study indicates that under present day atmospheric CO2 conditions, in the early Pliocene, the Antarctic ice sheets retreated significantly. Understanding the mechanisms driving this large-scale ice sheet retreat would enable us to assess whether current atmospheric CO2 concentrations will lead to the same ice sheet configuration once the Earth system has come to a new equilibrium state

User needs elicitation via analytic hierarchy process (AHP). A case study on a Computed Tomography (CT) scanner

Background: The rigorous elicitation of user needs is a crucial step for both medical device design and purchasing. However, user needs elicitation is often based on qualitative methods whose findings can be difficult to integrate into medical decision-making. This paper describes the application of AHP to elicit user needs for a new CT scanner for use in a public hospital. Methods: AHP was used to design a hierarchy of 12 needs for a new CT scanner, grouped into 4 homogenous categories, and to prepare a paper questionnaire to investigate the relative priorities of these. The questionnaire was completed by 5 senior clinicians working in a variety of clinical specialisations and departments in the same Italian public hospital. Results: Although safety and performance were considered the most important issues, user needs changed according to clinical scenario. For elective surgery, the five most important needs were: spatial resolution, processing software, radiation dose, patient monitoring, and contrast medium. For emergency, the top five most important needs were: patient monitoring, radiation dose, contrast medium control, speed run, spatial resolution. Conclusions: AHP effectively supported user need elicitation, helping to develop an analytic and intelligible framework of decision-making. User needs varied according to working scenario (elective versus emergency medicine) more than clinical specialization. This method should be considered by practitioners involved in decisions about new medical technology, whether that be during device design or before deciding whether to allocate budgets for new medical devices according to clinical functions or according to hospital department

Development and initial testing of a computer-based patient decision aid to promote colorectal cancer screening for primary care practice

BACKGROUND: Although colorectal cancer screening is recommended by major policy-making organizations, rates of screening remain low. Our aim was to develop a patient-directed, computer-based decision aid about colorectal cancer screening and investigate whether it could increase patient interest in screening. METHODS: We used content from evidence-based literature reviews and our previous decision aid research to develop a prototype. We performed two rounds of usability testing with representative patients to revise the content and format. The final decision aid consisted of an introductory segment, four test-specific segments, and information to allow comparison of the tests across several key parameters. We then conducted a before-after uncontrolled trial of 80 patients 50–75 years old recruited from an academic internal medicine practice. RESULTS: Mean viewing time was 19 minutes. The decision aid improved patients' intent to ask providers for screening from a mean score of 2.8 (1 = not at all likely to ask, 4 = very likely to ask) before viewing the decision aid to 3.2 afterwards (difference, 0.4; p < 0.0001, paired t-test). Most found the aid useful and reported that it improved their knowledge about screening. Sixty percent said they were ready to be tested, 18% needed more information, and 22% were not ready to be screened. Within 6 months of viewing, 43% of patients had completed screening tests. CONCLUSION: We conclude that a computer-based decision aid can increase patient intent to be screened and increase interest in screening. Practice Implications: This decision aid can be viewed by patients prior to provider appointments to increase motivation to be screened and to help them decide about which modality to use for screening. Further work is required to integrate the decision aid with other practice change strategies to raise screening rates to target levels

Instruments to assess the perception of physicians in the decision-making process of specific clinical encounters: a systematic review

<p>Abstract</p> <p>Background</p> <p>The measurement of processes and outcomes that reflect the complexity of the decision-making process within specific clinical encounters is an important area of research to pursue. A systematic review was conducted to identify instruments that assess the perception physicians have of the decision-making process within specific clinical encounters.</p> <p>Methods</p> <p>For every year available up until April 2007, PubMed, PsycINFO, Current Contents, Dissertation Abstracts and Sociological Abstracts were searched for original studies in English or French. Reference lists from retrieved studies were also consulted. Studies were included if they reported a self-administered instrument evaluating physicians' perceptions of the decision-making process within specific clinical encounters, contained sufficient description to permit critical appraisal and presented quantitative results based on administering the instrument. Two individuals independently assessed the eligibility of the instruments and abstracted information on their conceptual underpinnings, main evaluation domain, development, format, reliability, validity and responsiveness. They also assessed the quality of the studies that reported on the development of the instruments with a modified version of STARD.</p> <p>Results</p> <p>Out of 3431 records identified and screened for evaluation, 26 potentially relevant instruments were assessed; 11 met the inclusion criteria. Five instruments were published before 1995. Among those published after 1995, five offered a corresponding patient version. Overall, the main evaluation domains were: satisfaction with the clinical encounter (n = 2), mutual understanding between health professional and patient (n = 2), mental workload (n = 1), frustration with the clinical encounter (n = 1), nurse-physician collaboration (n = 1), perceptions of communication competence (n = 2), degree of comfort with a decision (n = 1) and information on medication (n = 1). For most instruments (n = 10), some reliability and validity criteria were reported in French or English. Overall, the mean number of items on the modified version of STARD was 12.4 (range: 2 to 18).</p> <p>Conclusion</p> <p>This systematic review provides a critical appraisal and repository of instruments that assess the perception physicians have of the decision-making process within specific clinical encounters. More research is needed to pursue the validation of the existing instruments and the development of patient versions. This will help researchers capture the complexity of the decision-making process within specific clinical encounters.</p

Should a colon cancer screening decision aid include the option of no testing? A comparative trial of two decision aids

<p>Abstract</p> <p>Background</p> <p>An important question in the development of decision aids about colon cancer (CRC) screening is whether to include an explicit discussion of the option of not being screened. We examined the effect of including or not including an explicit discussion of the option of deciding not to be screened in a CRC screening decision aid on subjective measures of decision aid content; interest in screening; and knowledge.</p> <p>Methods</p> <p>Adults ages 50–85 were assigned to view one of two versions of the decision aid. The two versions differed only in the inclusion of video segments of two men, one of whom decided against being screened. Participants completed questionnaires before and after viewing the decision aid to compare subjective measures of content, screening interest and intent, and knowledge between groups. Likert response categories (5-point) were used for subjective measures of content (eg. clarity, balance in favor/against screening, and overall rating), and screening interest. Knowledge was measured with a three item index and individual questions. Higher scores indicated favorable responses for subjective measures, greater interest, and better knowledge. For the subjective balance, lower numbers were associated with the impression of the decision aid favoring CRC screening.</p> <p>Results</p> <p>57 viewed the "with" version which included the two segments and 49 viewed the "without" version. After viewing, participants found the "without" version to have better subjective clarity about benefits of screening ("with" 3.4, "without" 4.1, <it>p </it>< 0.01), and to have greater clarity about downsides of screening ("with" 3.2, "without" 3.6, <it>p </it>= 0.03). The "with" version was considered to be less strongly balanced in favor of screening. ("with" 1.8, "without" 1.6, <it>p </it>= 0.05); but the "without" version received a better overall rating ("with" 3.5, "without" 3.8, <it>p </it>= 0.03). Groups did not differ in screening interest after viewing a decision aid or knowledge.</p> <p>Conclusion</p> <p>A decision aid with the explicit discussion of the option of deciding not to be screened appears to increase the impression that the program was not as strongly in favor of screening, but decreases the impression of clarity and resulted in a lower overall rating. We did not observe clinically important or statistically significant differences in interest in screening or knowledge.</p

Human Mas-related G protein-coupled receptors-X1 induce chemokine receptor 2 expression in rat dorsal root ganglia neurons and release of chemokine ligand 2 from the human LAD-2 mast cell line

Primate-specific Mas-related G protein-coupled receptors-X1 (MRGPR-X1) are highly enriched in dorsal root ganglia (DRG) neurons and induce acute pain. Herein, we analyzed effects of MRGPR-X1 on serum response factors (SRF) or nuclear factors of activated T cells (NFAT), which control expression of various markers of chronic pain. Using HEK293, DRG neuron-derived F11 cells and cultured rat DRG neurons recombinantly expressing human MRGPR-X1, we found activation of a SRF reporter gene construct and induction of the early growth response protein-1 via extracellular signal-regulated kinases-1/2 known to play a significant role in the development of inflammatory pain. Furthermore, we observed MRGPR-X1-induced up-regulation of the chemokine receptor 2 (CCR2) via NFAT, which is considered as a key event in the onset of neuropathic pain and, so far, has not yet been described for any endogenous neuropeptide. Up-regulation of CCR2 is often associated with increased release of its endogenous agonist chemokine ligand 2 (CCL2). We also found MRGPR-X1-promoted release of CCL2 in a human connective tissue mast cell line endogenously expressing MRGPR-X1. Thus, we provide first evidence to suggest that MRGPR-X1 induce expression of chronic pain markers in DRG neurons and propose a so far unidentified signaling circuit that enhances chemokine signaling by acting on two distinct yet functionally co-operating cell types. Given the important role of chemokine signaling in pain chronification, we propose that interruption of this signaling circuit might be a promising new strategy to alleviate chemokine-promoted pain