scholarly journals P134: Evaluating barriers to clinical decision rule integration: a qualitative analysis

CJEM ◽  
2016 ◽  
Vol 18 (S1) ◽  
pp. S122-S123
Author(s):  
D.E. Trumble
Keyword(s):  
Decision Making ◽  
Shared Decision Making ◽  
Decision Rule ◽  
Decision Rules ◽  
Clinical Decision ◽  
Shared Decision ◽  
Order Entry ◽  
Clinical Decision Rules ◽  
Potential Barriers ◽  
Inappropriate Use

Introduction: Clinical decision rules for computed tomography (CT) ordering in pulmonary embolism and mild traumatic brain injury have been shown to be under-used in clinical practice. Current literature does not explain why these validated decision rules continue to be under-used despite evidence of inappropriate use and increased costs. To better evaluate potential barriers to their use, qualitative methods involving focused interviews were conducted amongst emergency department (ED) physicians. Methods: Physicians were recruited via a brief presentation at Calgary Zone ED rounds. Ten attending and resident physicians (4 female, 6 male) were interviewed. Questions were designed to evaluate potential barriers to the integration of decision rules into the computerized order entry system. Interviews were audio-recorded and transcribed manually. A high-level thematic analysis was conducted to draw primary themes from open-ended questions, and responses were totaled for closed-ended questions. Results: Emerging themes suggest concerns surrounding timing of rule application in relation to test ordering, patient influences on ordering, and overuse reporting. All 10 physicians believed decision rules for CT ordering play a large role in the ED, and 8 were in favor of integration into the order entry system. However, over half expressed concern, noting that their thought process begins before order entry. A majority prioritized shared decision-making with patients. However, 8 indicated that patient expectations influence their ordering. A majority agreed that there is CT overuse in the ED, but many were hesitant in concluding that overuse was primarily physician dependent. Conclusion: Primary barriers to decision rule integration are timing of application, hesitation surrounding patient input, and uncertainty over data. Physicians often make decisions prior to order entry. Mobile copies of decision rules should be available to better facilitate compliance. Concerns over patient influence on ordering are common. Patient-friendly materials on clinical decision rules should be available to better facilitate shared decision making while still promoting decision rules. While overuse is agreed upon, many prefer to see and track their own ordering data before supporting a physician-targeted intervention. Data reports to physicians may help affirm physician-associated overuse, and reinforce their role in responsible resource utilization.

AHRQ White Paper: Use of Clinical Decision Rules for Point-of-Care Decision Support

2010 ◽  
Vol 30 (6) ◽  
pp. 712-721 ◽  
Author(s):  
Mark Ebell
Keyword(s):  
Decision Making ◽  
Clinical Practice ◽  
Shared Decision Making ◽  
Quantitative Data ◽  
Point Of Care ◽  
Decision Rules ◽  
Clinical Decision ◽  
Original Research ◽  
Shared Decision ◽  
Clinical Decision Rules

Translation of research into clinical practice remains a barrier, with inconsistent adoption of effective treatments and useful tests. Clinical decision rules (CDRs) integrate information from several clinical or laboratory findings to provide quantitative estimates of risk for a diagnosis or clinical outcome. They are increasingly reported in the literature and have the potential to provide a bridge that helps translate findings from original research studies into clinical practice. Unlike formal aids for shared decision making, they are pragmatic solutions that provide discrete quantitative data to aid clinicians and patients in decision making. These quantitative data can help inform the informal episodes of shared decision making that frequently take place at the point of care. Methods used to develop CDRs include expert opinion, multivariate models, point scores, and classification and regression trees Desirable CDRs are valid (make accurate predictions of risk), relevant (have been shown to improve patient-oriented outcomes), are easy to use at the point of care, are acceptable (with good face validity and transparency of recommendations), and are situated in the clinical context. The latter means that the rule places patients in risk groups that are clinically useful (i.e., below the test threshold or above the treatment threshold) and does so in adequate numbers to make use of the CDR a worthwhile investment in time. CDRs meeting these criteria should be integrated with electronic health records, populating the point score or decision tree with individual patient data and performing calculations automatically to streamline decision making.

scholarly journals Implementing an Electronic Clinical Decision Support Tool Into Routine Care: A Qualitative Study of Stakeholders’ Perceptions of a Post-Mastectomy Breast Reconstruction Tool

2021 ◽  
Vol 6 (2) ◽  
pp. 238146832110420
Author(s):  
Jessica Boateng ◽  
Clara N. Lee ◽  
Randi E. Foraker ◽  
Terence M. Myckatyn ◽  
Kimi Spilo ◽  
...  
Keyword(s):  
Decision Making ◽  
Decision Support ◽  
Breast Reconstruction ◽  
Shared Decision Making ◽  
Clinical Decision Support ◽  
Clinical Decision ◽  
Routine Care ◽  
Evidence Based ◽  
Shared Decision ◽  
Consultation Time

Objective. To explore barriers and facilitators to implementing an evidence-based clinical decision support (CDS) tool (BREASTChoice) about post-mastectomy breast reconstruction into routine care. Materials and Methods. A stakeholder advisory group of cancer survivors, clinicians who discuss and/or perform breast reconstruction in women with cancer, and informatics professionals helped design and review the interview guide. Based on the Consolidated Framework for Implementation Research (CFIR), we conducted qualitative semistructured interviews with key stakeholders (patients, clinicians, informatics professionals) to explore intervention, setting characteristics, and process-level variables that can impact implementation. Interviews were transcribed, coded, and analyzed based on the CFIR framework using both inductive and deductive methods. Results. Fifty-seven potential participants were contacted; 49 (85.9%) were eligible, and 35 (71.4%) were enrolled, continuing until thematic saturation was reached. Participants consisted of 13 patients, 13 clinicians, and 9 informatics professionals. Stakeholders thought that BREASTChoice was useful and provided patients with an evidence-based source of information about post-mastectomy breast reconstruction, including their personalized risks. They felt that BREASTChoice could support shared decision making, improve workflow, and possibly save consultation time, but were uncertain about the best time to deliver BREASTChoice to patients. Some worried about cost, data availability, and security of integrating the tool into an electronic health record. Most acknowledged the importance of showing clinical utility to gain institutional buy-in and encourage routine adoption. Discussion and Conclusion. Stakeholders felt that BREASTChoice could support shared decision making, improve workflow, and reduce consultation time. Addressing key questions such as cost, data integration, and timing of delivering BREASTChoice could build institutional buy-in for CDS implementation. Results can guide future CDS implementation studies.

scholarly journals P017: When the rules hit the road: how emergency physicians make decisions in the era of the Clinical Decision Rules

CJEM ◽  
2018 ◽  
Vol 20 (S1) ◽  
pp. S62-S63
Author(s):  
T. M. Chan ◽  
M. Mercuri ◽  
K. de Wit
Keyword(s):  
Decision Making ◽  
Iterative Process ◽  
Decision Rules ◽  
Clinical Decision ◽  
Leg Pain ◽  
Diagnostic Process ◽  
Think Aloud ◽  
Emergency Physicians ◽  
Clinical Decision Rules ◽  
Diagnostic Uncertainty

Introduction: The diagnostic process is wrought with potential sources of error. Psychologists seek to coach physicians to refine their cognition. Researchers try to create cognitive scaffolds to guide decision-making. Physicians however, are caught in middle between their own daily cognitive processes and these external theories that might influence their behaviour. Few attempts have been made to understand how experienced clinicians integrate guidelines or clinical decision rules (CDRs) into their decision-making. We sought to explore experienced clinicians decision-making via a simulated exercise, to develop a model of how physicians integrate CDRs into their diagnostic thinking. Methods: From July 2015-March 2016, 16 practicing emergency physicians (EPs) were interviewed via a think aloud protocol study. Six cases were constructed and video recorded as prompts to spur the clinicians to think aloud and describe their approach to the cases. Cases were designed to be slightly suggestive for pulmonary embolism or deep vein thrombosis, since these conditions are associated with CDRs. Using a constructivist grounded theory analysis, three investigators independently reviewed the transcripts from the interviews, meeting regularly to discuss emergent themes and subthemes until sufficiency was reached. Disagreements about themes were resolved by discussion and consensus. Results: Our analysis suggests that physicians engage in an iterative process when they are faced with undifferentiated chest pain and leg pain cases. After generating an original differential diagnosis, EPs engage in an iterative diagnostic process. They flip between hypothesis-driven data collection (e.g. history, physical exam, tests) and analysis of this data, and use this process to weigh probabilities of various diagnoses. EPs only apply CDRs once they are sufficiently suspicious of a diagnosis requiring guidance from a CDR and when they experience diagnostic uncertainty or wish to bolster their decision with evidence. Conclusion: EP cognition around diagnosis is a dynamic and iterative process, and may only peripherally integrate relevant CDRs if a threshold level of suspicion is met. Our findings may be useful for improving knowledge translation of CDRs and prevent diagnostic error.

scholarly journals Shared Decision Making

2021 ◽  
Vol 02 (01) ◽  
pp. 111-117
Author(s):  
Wei Wang
Keyword(s):  
Decision Making ◽  
Clinical Practice ◽  
Emergency Management ◽  
Shared Decision Making ◽  
State Of The Art ◽  
Clinical Decision ◽  
Shared Decision ◽  
Patient Centered ◽  
Significant Potential

Shared decision making (SDM) is a process by which physicians and patients jointly participate in choosing to pursue one of several alternatives in a clinical decision. It is most relevant for decisions that involve significant potential harms and benefits with tradeoffs and uncertainty. This paper provides a state-of-the-art review about SDM covering its concept, value, implementation and application in emergency management and communication. SDM is valuable in the process of making decisions which patients may benefit most from, thus resulting in satisfying patient-centered outcomes. Although SDM can be challenging to incorporate into clinical practice, it is likely to become a useful tool of communication in future.

scholarly journals Individual Value Clarification Methods Based on Conjoint Analysis: A Systematic Review of Common Practice in Task Design, Statistical Analysis, and Presentation of Results

2018 ◽  
Vol 38 (6) ◽  
pp. 746-755 ◽  
Author(s):  
Marieke G.M. Weernink ◽  
Janine A. van Til ◽  
Holly O. Witteman ◽  
Liana Fraenkel ◽  
Maarten J. IJzerman
Keyword(s):  
Decision Making ◽  
Shared Decision Making ◽  
Conjoint Analysis ◽  
Decision Aids ◽  
Clinical Decision ◽  
Task Design ◽  
Shared Decision ◽  
Attribute Importance ◽  
Barriers To Implementation ◽  
Choice Tasks

Background. There is an increased practice of using value clarification exercises in decision aids that aim to improve shared decision making. Our objective was to systematically review to which extent conjoint analysis (CA) is used to elicit individual preferences for clinical decision support. We aimed to identify the common practices in the selection of attributes and levels, the design of choice tasks, and the instrument used to clarify values. Methods. We searched Scopus, PubMed, PsycINFO, and Web of Science to identify studies that developed a CA exercise to elicit individual patients’ preferences related to medical decisions. We extracted data on the above-mentioned items. Results. Eight studies were identified. Studies included a fixed set of 4–8 attributes, which were predetermined by interviews, focus groups, or literature review. All studies used adaptive conjoint analysis (ACA) for their choice task design. Furthermore, all studies provided patients with their preference results in real time, although the type of outcome that was presented to patients differed (attribute importance or treatment scores). Among studies, patients were positive about the ACA exercise, whereas time and effort needed from clinicians to facilitate the ACA exercise were identified as the main barriers to implementation. Discussion. There is only limited published use of CA exercises in shared decision making. Most studies resembled each other in design choices made, but patients received different feedback among studies. Further research should focus on the feedback patients want to receive and how the CA results fit within the patient–physician dialogue.

scholarly journals Understanding shared decision-making experience among vulnerable population: Focus group with food bank clients

2020 ◽  
pp. 1-8
Author(s):  
Young Ji Lee ◽  
Tiffany Brazile ◽  
Francesca Galbiati ◽  
Megan Hamm ◽  
Cindy Bryce ◽  
...  
Keyword(s):  
Decision Making ◽  
Focus Groups ◽  
Shared Decision Making ◽  
Vulnerable Populations ◽  
Clinical Decision Making ◽  
Decision Aids ◽  
Clinical Decision ◽  
Therapeutic Options ◽  
Shared Decision ◽  
Food Bank

Abstract Introduction: Shared decision-making (SDM) is a critical component of delivering patient-centered care. Members of vulnerable populations may play a passive role in clinical decision-making; therefore, understanding their prior decision-making experiences is a key step to engaging them in SDM. Objective: To understand the previous healthcare experiences and current expectations of vulnerable populations on clinical decision-making regarding therapeutic options. Methods: Clients of a local food bank were recruited to participate in focus groups. Participants were asked to share prior health decision experiences, explain difficulties they faced when making a therapeutic decision, describe features of previous satisfactory decision-making processes, share factors under consideration when choosing between treatment options, and suggest tools that would help them to communicate with healthcare providers. We used the inductive content analysis to interpret data gathered from the focus groups. Results: Twenty-six food bank clients participated in four focus groups. All participants lived in areas of socioeconomic disadvantage. Four themes emerged: prior negative clinical decision-making experience with providers, patients preparing to engage in SDM, challenges encountered during the decision-making process, and patients’ expectations of decision aids. Participants also reported they were unable to discuss therapeutic options at the time of decision-making. They also expressed financial concerns and the need for sufficiently detailed information to evaluate risks. Conclusion: Our findings suggest the necessity of developing decision aids that would improve the engagement of vulnerable populations in the SDM process, including consideration of affordability, use of patient-friendly language, and incorporation of drug–drug and drug–food interactions information.

Hereditary angioedema and shared decision making

2020 ◽  
Vol 41 (6) ◽  
pp. S55-S60 ◽  
Author(s):  
Russell A. Settipane ◽  
Don A. Bukstein ◽  
Marc A. Riedl
Keyword(s):  
Decision Making ◽  
Shared Decision Making ◽  
Hereditary Angioedema ◽  
Clinical Decision Making ◽  
Unmet Need ◽  
Clinical Decision ◽  
Therapeutic Agents ◽  
Shared Decision ◽  
Widespread Implementation ◽  
High Degree

Clinical decision-making in hereditary angioedema (HAE) management involves a high degree of complexity given the number of therapeutic agents that are available and the risk for significant morbidity and potential mortality attributable to the disease. Given this complexity, there is an opportunity to develop shared decision-making (SDM) aids and/or tools that would facilitate the interactive participation of practitioners and patients in the SDM process. This article reviews the general constructs of SDM, the unmet need for SDM in HAE, and the steps necessary to create a SDM tool specific for HAE, and outlines the challenges that must be navigated to guide the establishment and widespread implementation of SDM in the management of HAE.

scholarly journals Downgrade of cardiac defibrillator devices to pacemakers in elderly heart failure patients: clinical considerations and the importance of shared decision-making

2021 ◽  
Vol 29 (5) ◽  
pp. 243-252
Author(s):  
H. F. Groenveld ◽  
J. E. Coster ◽  
D. J. van Veldhuisen ◽  
M. Rienstra ◽  
Y. Blaauw ◽  
...  
Keyword(s):  
Heart Failure ◽  
Decision Making ◽  
Elderly Patients ◽  
Shared Decision Making ◽  
Large Scale ◽  
Clinical Decision Making ◽  
Clinical Decision ◽  
Short Review ◽  
Implantable Cardioverter Defibrillators ◽  
Shared Decision

AbstractImplantable cardioverter defibrillators are implanted on a large scale in patients with heart failure (HF) for the prevention of sudden cardiac death. There are different scenarios in which defibrillator therapy is no longer desired or indicated, and this is occurring increasingly in elderly patients. Usually device therapy is continued until the device has reached battery depletion. At that time, the decision needs to be made to either replace it or to downgrade to a pacing-only device. This decision is dependent on many factors, including the vitality of the patient and his/her preferences, but may also be influenced by changes in recommendations in guidelines. In the last few years, there has been an increased awareness that discussions around these decisions are important and useful. Advanced care planning and shared decision-making have become important and are increasingly recognised as such. In this short review we describe six elderly patients with HF, in whose cases we discussed these issues, and we aim to provide some scientific and ethical rationale for clinical decision-making in this context. Current guidelines advocate the discussion of end-of-life options at the time of device implantation, and physicians should realise that their choices influence patients’ options in this critical phase of their illness.

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