Reimagining the Humble but Mighty Pen: Quality Measurement and Naturalistic Decision Making

2018 ◽  
Vol 12 (3) ◽  
pp. 198-201 ◽  
Author(s):  
Eric C. Schneider
Keyword(s):  
Decision Making ◽  
Best Practices ◽  
Pay For Performance ◽  
Quality Measurement ◽  
Daily Practice ◽  
Cost Of Care ◽  
Naturalistic Decision Making ◽  
Joint Decisions ◽  
The Cost

Much of the health system’s avoidable spending may be driven by doctors’ decision making. Past studies demonstrated potentially consequential and costly inconsistencies between the actual decisions that clinicians make in daily practice and optimal evidence-based decisions. This commentary examines the “best practices regimen” through the lens of the quality measurement movement.  Although quality measures have proliferated via public reporting and pay-for-performance programs, evidence for their impact on quality of care is scant; the cost of care has continued to rise; and the environment for clinical decisions may not have improved. Naturalistic decision making offers a compelling alternative conceptual frame for quality measurement. An alternative quality measurement system could build on insights from naturalistic decision making to optimize doctors’ and patients’ joint decisions, improve patients’ health outcomes, and perhaps slow the growth of health care spending in the future.

scholarly journals The Cost of Information in Dependence on the Investor Relation to the Risk

2012 ◽  
Vol 11 (1) ◽  
pp. 73-85
Author(s):  
Simona Hašková
Keyword(s):  
Decision Making ◽  
Utility Theory ◽  
Investment Decision ◽  
Investment Decisions ◽  
Reliable Estimate ◽  
Ordinary People ◽  
Cardinal Utility ◽  
Finance Theory ◽  
The Cost

Abstract The contribution sets simple mathematic models describing and explaining the way of behavior of various types of investors (the private and institutionalized ones). The models come from the cardinal utility theory which is used for explaining the connection between the subjective relationship towards risk and some pathologic phenomenon of finance theory (for example the moral hazard question of institutionalized investors) and takes into account the decision making of both ordinary people and professional investors. A reliable estimate of the economic surroundings where the investment should run contributes significantly to a quality of the particular investment decisions. The article contributes to a quality of the investment decision by the original and primary approach to pricing information that lowers the uncertainty in occurrences of the relevant scenarios of the project’s development. At the conclusion there is shown how the shift of the decision breaking point shapes the amount of the acceptable price of the information.

Naturalistic Decision Making and the Practice of Health Care

2018 ◽  
Vol 12 (3) ◽  
pp. 178-193 ◽  
Author(s):  
Paul R. Falzer
Keyword(s):  
Health Care ◽  
Decision Making ◽  
Best Practices ◽  
Clinical Decision Making ◽  
Resistance To Change ◽  
Care Practice ◽  
Evidence Based ◽  
Naturalistic Decision Making ◽  
Late 20Th Century ◽  
Care Community

A recent essay in this journal identified health care as a fertile domain for extending the reach of naturalistic decision making (NDM). It targeted the “best practices regimen,” a host of initiatives begun in the late 20th century that address problems in service delivery, skyrocketing costs, and impediments in transforming products of basic science into effective treatments. Of particular importance are efforts to base treatment decisions on empirical research findings and to gauge the quality of decisions by their conformance to evidence-based practices. The challenges that the essay identified and the ways of addressing these challenges are well known in the health care community. They have had limited impact owing to several factors, including how advocates of the best practices regimen envision clinical decision making and their tendency to equate the exercise of skill with resistance to change. This paper describes the regimen’s concept of decision making and its principles and deficiencies. It also identifies a conundrum: oversimplification prevents complexity from being recognized; as a result, evidence-based recommendations frequently have unforeseeable and deleterious consequences. The paper proposes that NDM is well positioned to address these problems and make a valuable contribution to health care practice. It illustrates NDM-based theories and concepts with a research example and describes their ability to address complex issues that arise in treating chronic illnesses.

scholarly journals Mathematical modeling for a multiproduct manufacturing system featuring postponement, external suppliers, overtime, and scrap

2022 ◽  
Vol 13 (1) ◽  
pp. 1-12
Author(s):  
Yuan-Shyi P. Chiu ◽  
Jian-Hua Lian ◽  
Victoria Chiu ◽  
Yunsen Wang ◽  
Hsiao-Chun Wu
Keyword(s):  
Decision Making ◽  
Cost Function ◽  
Due Dates ◽  
Numerical Illustration ◽  
Screening Process ◽  
Multiproduct Manufacturing ◽  
The Cost ◽  
Decision Making Model ◽  
Mathematical Derivation

Manufacturing firms operating in today’s competitive global markets must continuously find the appropriate manufacturing scheme and strategies to effectively meet customer needs for various types of quality of merchandise under the constraints of short order lead-time and limited in-house capacity. Inspired by the offering of a decision-making model to aid smooth manufacturers’ operations, this study builds an analytical model to expose the influence of the outsourcing of common parts, postponement policies, overtime options, and random scrapped items on the optimal replenishment decision and various crucial system performance indices of the multiproduct problem. A two-stage fabrication scheme is presented to handle the products’ commonality and the uptime-reduced strategies to satisfy the short amount of time before the due dates of customers’ orders. A screening process helps identify and remove faulty items to ensure the finished lot’s anticipated quality. Mathematical derivation assists us in finding the manufacturing relevant total cost function. The differential calculus helps optimize the cost function and determine the optimal stock-replenishing rotation cycle policy. Lastly, a simulated numerical illustration helps validate our research result’s applicability and demonstrate the model’s capability to disclose the crucial managerial insights and facilitate manufacturing-relevant decision making.

scholarly journals The cost-effectiveness of physician assistants/associates: A systematic review of international evidence

PLoS ONE ◽  
2021 ◽  
Vol 16 (11) ◽  
pp. e0259183
Author(s):  
G. T. W. J. van den Brink ◽  
R. S. Hooker ◽  
A. J. Van Vught ◽  
H. Vermeulen ◽  
M. G. H. Laurant
Keyword(s):  
Systematic Review ◽  
Quality Of Care ◽  
Cost Effectiveness ◽  
Physician Assistants ◽  
Labor Cost ◽  
Cost Of Care ◽  
Complementary Role ◽  
Care Outcomes ◽  
The Cost

Background The global utilization of the physician assistant/associate (PA) is growing. Their increasing presence is in response to the rising demands of demographic changes, new developments in healthcare, and physician shortages. While PAs are present on four continents, the evidence of whether their employment contributes to more efficient healthcare has not been assessed in the aggregate. We undertook a systematic review of the literature on PA cost-effectiveness as compared to physicians. Cost-effectiveness was operationalized as quality, accessibility, and the cost of care. Methods and findings Literature to June 2021 was searched across five biomedical databases and filtered for eligibility. Publications that met the inclusion criteria were categorized by date, country, design, and results by three researchers independently. All studies were screened with the Risk of Bias in Non-randomised Studies—of Interventions (ROBIN-I) tool. The literature search produced 4,855 titles, and after applying criteria, 39 studies met inclusion (34 North America, 4 Europe, 1 Africa). Ten studies had a prospective design, and 29 were retrospective. Four studies were assessed as biased in results reporting. While most studies included a small number of PAs, five studies were national in origin and assessed the employment of a few hundred PAs and their care of thousands of patients. In 34 studies, the PA was employed as a substitute for traditional physician services, and in five studies, the PA was employed in a complementary role. The quality of care delivered by a PA was comparable to a physician’s care in 15 studies, and in 18 studies, the quality of care exceeded that of a physician. In total, 29 studies showed that both labor and resource costs were lower when the PA delivered the care than when the physician delivered the care. Conclusions Most of the studies were of good methodological quality, and the results point in the same direction; PAs delivered the same or better care outcomes as physicians with the same or less cost of care. Sometimes this efficiency was due to their reduced labor cost and sometimes because they were more effective as producers of care and activity.

Abstract 166: Use of Risk Stratification for the Management of TIA in the Emergency Department: Focus Group Results.

2012 ◽  
Vol 5 (suppl_1) ◽  
Author(s):  
Mathew J Reeves ◽  
Brian Mavis ◽  
Thomas Wilkins ◽  
Margaret Holmes Rovner ◽  
Michael Brown ◽  
...  
Keyword(s):  
Decision Making ◽  
Patient Care ◽  
Stroke Risk ◽  
Prediction Rule ◽  
Clinical Prediction Rule ◽  
Cost Of Care ◽  
Risk Patient ◽  
Clinical Prediction ◽  
Moderate Risk ◽  
The Cost

Background: Evaluation of TIA cases in the emergency department (ED) represents a clinical dilemma because no firm guidelines exist as to their disposition (hospitalization vs. out-patient care). The ABCD 2 clinical prediction rule risk stratifies patients but little is known about how Emergency Medicine physicians (EMPs) use the rule in clinical decision making. We undertook focus groups with EMPs to determine their attitudes and use of the ABCD 2 score, and to understand how information on baseline risk, costs, compliance, and feasibility affect their decision making. Methods: Physicians from 2 EM practice groups in Michigan were invited to attend a focus group meeting. Data were collected on their knowledge, attitudes, and use of the ABCD 2 clinical prediction rule in the evaluation of TIA cases. Using a case vignette of a moderate risk patient (ABCD 2 score = 4, 7-day stroke risk = 6%), physicians were asked to choose between hospitalization or discharge for out-patient care. We then changed several baseline conditions, including 7-day stroke risk, health care costs, and compliance with out-patient follow-up, to determine under what conditions they altered the initial disposition decision. Results: Twenty two EMPs participated; all worked in community-based hospitals, 91% were male, 95% were EM board certified with an average of 16.5 years of EM experience. Respondents reported seeing an average of 6.7 (SD= 4.6) TIA patients per month. Sixty four percent (14/22) were familiar with the ABCD 2 score, but only 9% (2/22) used it regularly. Almost 60% (13/22) initially chose to hospitalize the moderate risk patient. Increasing the cost of the episode of care (from $3000 to $9000) did not change the decision to hospitalize for the majority (8/13, 62%) of EMPs. Only when 7-day stroke risk was lowered from 6% to 1% did the majority of EMPs (11/13, 85%) change their decision from hospitalization to outpatient care. Forty percent (9/22) initially chose to manage the moderate risk patient as an out-patient. A small increase in the cost of care (from $3000 to $3500) resulted in 56% (5/9) EMPs switching their decision from out-patient care to hospitalization, while a modest increase in stroke risk (from 6% to 10%) resulted in 78% (7/9) switching their initial decision. The choice of out-patient care was also influenced by the likelihood that patients would complete testing in the out-patient setting; if compliance dropped from 100% to 80% then half of the EMPs switched their decision from out-patient care to hospitalization. Increasing the number of hours that a patient would need to complete testing (from 4 to 12 hours) only had a modest impact on physician decision making. Conclusions: The ABCD 2 score was rarely used in practice. The decision to hospitalize was relatively insensitive to cost of care; 7-day stroke risk only influenced the decision when reduced to virtual certainty (1%). The decision to use out-patient care was more sensitive to cost of care, increases in stroke risk, and compliance in the out-patient setting. These data suggest future studies should focus on acceptable outpatient risks and costs to increase adoption of clinical prediction rules and appropriate decision making for TIA cases.

Naturalistic Decision Making: A Model to Overcome Methodological Challenges in the Study of Critical Care Nurses’ Decision Making About Patients’ Hemodynamic Status

2003 ◽  
Vol 12 (3) ◽  
pp. 206-211 ◽  
Author(s):  
Judy Currey ◽  
Mari Botti
Keyword(s):  
Decision Making ◽  
Critical Care ◽  
Well Being ◽  
Critical Care Nurses ◽  
Naturalistic Decision Making ◽  
Hemodynamic Status ◽  
Hemodynamic Assessment ◽  
Assessment And Treatment ◽  
Methodological Approaches

The quality of critical care nurses’ decision making about patients’ hemodynamic status in the immediate period after cardiac surgery is important for the patients’ well-being and, at times, survival. The way nurses respond to hemodynamic cues varies according to the nurses’ skills, experiences, and knowledge. Variability in decisions is also associated with the inherent complexity of hemodynamic monitoring. Previous methodological approaches to the study of hemodynamic assessment and treatment decisions have ignored the important interplay between nurses, the task, and the environment in which these decisions are made. The advantages of naturalistic decision making as a framework for studying the manner in which nurses make decisions are presented.

A system for logging incontinence events using a simple disposable sensor

2003 ◽  
Vol 217 (4) ◽  
pp. 305-310 ◽  
Author(s):  
G Cusick ◽  
A Birkett ◽  
S Clarke-O'Neill ◽  
M Fader ◽  
A M Cottenden
Keyword(s):  
Quality Of Life ◽  
Nursing Care ◽  
Cost Of Care ◽  
Assessment System ◽  
Regular Pattern ◽  
Disposable Sensor ◽  
Form Part ◽  
Incontinence Pads ◽  
The Cost

Many elderly people entering residential or nursing care are already incontinent to some degree, relying on incontinence pads to deal with the consequences. A proportion of these people have been shown to exhibit a regular pattern in their incontinence, which opens up the possibility of mitigating the problem by instituting an individual toileting regime for the person. This can reduce their reliance on incontinence pads, both improving their quality of life, and reducing the cost of care. This paper covers the development and evaluation of a sensor for detecting incontinence events, suitable for use in this setting, and describes the design of an associated electronic logger. The devices form part of an assessment system intended to identify a pattern in incontinence where it exists, and to help with the design of the toilet regime for an individual. The requirement is that the system must reliably record incontinence events, and present the information describing them in a manner appropriate to the users of the devices, who are likely to be non-technical and non-specialist.

Talking About the Cost of Care: A Critical Component of Shared Decision Making

2020 ◽  
Vol 112 (2) ◽  
pp. 225-228
Author(s):  
Gwen Darien ◽  
Christine Wilson ◽  
Alan Balch ◽  
Rebekah Angove
Keyword(s):  
Decision Making ◽  
Shared Decision Making ◽  
Cost Of Care ◽  
Shared Decision ◽  
Critical Component ◽  
The Cost
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