scholarly journals Development and Validation of Nine Deprescribing Algorithms for Patients on Hemodialysis to Decrease Polypharmacy

2020 ◽  
Vol 7 ◽  
pp. 205435812096867
Author(s):  
Melissa J. Lefebvre ◽  
Patrick C. K. Ng ◽  
Arlene Desjarlais ◽  
Dennis McCann ◽  
Blair Waldvogel ◽  
...  
Keyword(s):  
Nurse Practitioners ◽  
Content Validity ◽  
Clinical Decision Making ◽  
Clinical Decision ◽  
Face Validity ◽  
Specific Patient ◽  
Expert Opinions ◽  
Safety Parameters ◽  
Clinical Tools ◽  
Strongly Agree

Background: Polypharmacy is ubiquitous in patients on hemodialysis (HD), and increases risk of adverse events, medication interactions, nonadherence, and mortality. Appropriately applied deprescribing can potentially minimize polypharmacy risks. Existing guidelines are unsuitable for nephrology clinicians as they lack specific instructions on how to deprescribe and which safety parameters to monitor. Objective: To develop and validate deprescribing algorithms for nine medication classes to decrease polypharmacy in patients on HD. Design: Questionnaires and materials sent electronically. Participants: Nephrology practitioners across Canada (nephrologists, nurse practitioners, renal pharmacists). Methods: A literature search was performed to develop the initial algorithms via Lynn’s method for development of content-valid clinical tools. Content and face validity of the algorithms was evaluated over three interview rounds using Lynn’s method for determining content validity. Canadian nephrology clinicians each evaluated three algorithms (15 clinicians per round, 45 clinicians in total) by rating each algorithm component on a four-point Likert scale for relevance; face validity was rated on a five-point scale. After each round, content validity index of each component was calculated and revisions made based on feedback. If content validity was not achieved after three rounds, additional rounds were completed until content validity was achieved. Results: After three rounds of validation, six algorithms achieved content validity. After an additional round, the remaining three algorithms achieved content validity. The proportion of clinicians rating each face validity statement as “Agree” or “Strongly Agree” ranged from 84% to 95% (average of all five questions, across three rounds). Limitations: Algorithm development was guided by existing deprescribing protocols intended for the general population and the expert opinions of our study team, due to a lack of background literature on HD-specific deprescribing protocols. There is no universally accepted method for the validation of clinical decision-making tools. Conclusions: Nine medication-specific deprescribing algorithms for patients on HD were developed and validated by clinician review. Our algorithms are the first medication-specific, patient-centric deprescribing guidelines developed and validated for patients on HD.

scholarly journals The I-DECIDED clinical decision-making tool for peripheral intravenous catheter assessment and safe removal: a clinimetric evaluation

BMJ Open ◽  
2020 ◽  
Vol 10 (1) ◽  
pp. e035239 ◽  
Author(s):  
Gillian Ray-Barruel ◽  
Marie Cooke ◽  
Vineet Chopra ◽  
Marion Mitchell ◽  
Claire M Rickard
Keyword(s):  
Decision Making ◽  
Vascular Access ◽  
Content Validity ◽  
Online Survey ◽  
Clinical Decision Making ◽  
Decision Time ◽  
Face Validity ◽  
Intravenous Catheter ◽  
Rater Reliability ◽  
Peripheral Intravenous Catheter

ObjectiveTo describe the clinimetric validation of the I-DECIDED tool for peripheral intravenous catheter assessment and decision-making.Design and settingI-DECIDED is an eight-step tool derived from international vascular access guidelines into a structured mnemonic for device assessment and decision-making. The clinimetric evaluation process was conducted in three distinct phases.MethodsInitial face validity was confirmed with a vascular access working group. Next, content validity testing was conducted via online survey with vascular access experts and clinicians from Australia, the UK, the USA and Canada. Finally, inter-rater reliability was conducted between 34 pairs of assessors for a total of 68 peripheral intravenous catheter (PIVC) assessments. Assessments were timed to ensure feasibility, and the second rater was blinded to the first’s findings. Content validity index (CVI), mean item-level CVI (I-CVI), internal consistency, mean proportion of agreement, observed and expected inter-rater agreements, and prevalence-adjusted bias-adjusted kappas (PABAK) were calculated. Ethics approvals were obtained from university and hospital ethics committees.ResultsThe I-DECIDED tool demonstrated strong content validity among international vascular access experts (n=7; mean I-CVI=0.91; mean proportion of agreement=0.91) and clinicians (n=11; mean I-CVI=0.93; mean proportion of agreement=0.94), and high inter-rater reliability in seven adult medical-surgical wards of three Australian hospitals. Overall, inter-rater reliability was 87.13%, with PABAK for each principle ranging from 0.5882 (‘patient education’) to 1.0000 (‘document the decision’). Time to complete assessments averaged 2 min, and nurse-reported acceptability was high.ConclusionThis is the first comprehensive, evidence-based, valid and reliable PIVC assessment and decision tool. We recommend studies to evaluate the outcome of implementing this tool in clinical practice.Trial registration number12617000067370

Is comparative effectiveness research emphasized in oncologic residency training programs? Results of a national survey.

2013 ◽  
Vol 31 (15_suppl) ◽  
pp. e17577-e17577 ◽  
Author(s):  
Nicholas George Zaorsky ◽  
Jordan Hess ◽  
Robert Benjamin Den ◽  
Voichita Bar-Ad ◽  
Joanne Filicko ◽  
...  
Keyword(s):  
Comparative Effectiveness Research ◽  
Comparative Effectiveness ◽  
Clinical Decision Making ◽  
Training Programs ◽  
Medical Condition ◽  
Clinical Decision ◽  
Effectiveness Research ◽  
Continuous Quality ◽  
Effectiveness And Efficiency ◽  
Strongly Agree

e17577 Background: Comparative effectiveness research (CER) is informally defined as an assessment of all available efficacious options for a specific medical condition, with intent to estimate effectiveness and efficiency in specific subpopulations. The American Recovery and Reinvestment Act of 2009 allocated $1.8 B to increase CER and train physicians in its practice. Although program directors (PDs) of medical oncology (MO) and radiation oncology (RO) training programs know that CER is emphasized nationally, it is unknown if CER is emphasized in oncological training programs themselves. We examine the emphasis of CER in MO and RO training programs. Methods: A web-based, anonymous survey was sent to RO PDs (n = 85) and chief residents (CRs; 98); and MO PDs (99), asking them to forward a link to fellows (Fs; 160). Mean weighted Likerts (MWLs ± standard deviations [SDs]) were calculated from scales (1, strongly disagree; 3, neutral; 5, strongly agree). Results: The response rates for RO PDs, RO CRs, MO PDs, and MO Fs were 20%, 21%, 11%, and 10% (combined, 15%, 68/442). Respondents had mixed beliefs in having a clear definition of CER (MWL, 3.1 ± 1.2); their programs encouraging CER (3.2 ± 1.2); including a course on CER (2.3 ± 0.9); or discussing the differences among efficacy, effectiveness, and efficiency (2.9 ± 0.9). Retrospective cohort studies were easy to perform at institutions (4.3 ± 0.8), but less so CER (3.1 ± 1.3). Respondents believed their programs’ research integrated some core values of CER, including comparing treatments to influence clinical decision making (4.6 ± 0.7). Respondents believed CER was important (4.3 ± 0.7); 47% would divert funding from other types of research toward CER; 35% would, only if funding for other research was unaffected. Conclusions: CER is not emphasized in oncologic training programs, and most PDs and trainees cannot clearly define CER. In the era of health care reform and potential future payment reforms, it is anticipated that CER will become an increasingly important component of evidence-based medicine and continuous quality improvement. This study identifies a need for oncology training programs to incorporate education about CER into their curricula.

Content and Process in Clinical Decision-Making by Nurse Practitioners

1992 ◽  
Vol 24 (2) ◽  
pp. 153-158 ◽  
Author(s):  
Joyce E. White ◽  
Donna G. Nativio ◽  
Shirley N. Kobert ◽  
Sandra J. Engberg
Keyword(s):  
Decision Making ◽  
Nurse Practitioners ◽  
Clinical Decision Making ◽  
Clinical Decision

scholarly journals Interactive Visual Displays for Interpreting the Results of Clinical Trials: Formative Evaluation With Case Vignettes (Preprint)

2018 ◽  
Author(s):  
Jiantao Bian ◽  
Charlene Weir ◽  
Prasad Unni ◽  
Damian Borbolla ◽  
Thomas Reese ◽  
...  
Keyword(s):  
Information Needs ◽  
Formative Evaluation ◽  
Clinical Decision Making ◽  
Point Of Care ◽  
Clinical Decision ◽  
Visual Displays ◽  
Specific Patient ◽  
Information Displays ◽  
Case Vignettes ◽  
Comparison Of The Results

BACKGROUND At the point of care, evidence from randomized controlled trials (RCTs) is underutilized in helping clinicians meet their information needs. OBJECTIVE To design interactive visual displays to help clinicians interpret and compare the results of relevant RCTs for the management of a specific patient, and to conduct a formative evaluation with physicians comparing interactive visual versus narrative displays. METHODS We followed a user-centered and iterative design process succeeded by development of information display prototypes as a Web-based application. We then used a within-subjects design with 20 participants (8 attendings and 12 residents) to evaluate the usability and problem-solving impact of the information displays. We compared subjects’ perceptions of the interactive visual displays versus narrative abstracts. RESULTS The resulting interactive visual displays present RCT results side-by-side according to the Population, Intervention, Comparison, and Outcome (PICO) framework. Study participants completed 19 usability tasks in 3 to 11 seconds with a success rate of 78% to 100%. Participants favored the interactive visual displays over narrative abstracts according to perceived efficiency, effectiveness, effort, user experience and preference (all P values <.001). CONCLUSIONS When interpreting and applying RCT findings to case vignettes, physicians preferred interactive graphical and PICO-framework-based information displays that enable direct comparison of the results from multiple RCTs compared to the traditional narrative and study-centered format. Future studies should investigate the use of interactive visual displays to support clinical decision making in care settings and their effect on clinician and patient outcomes.

scholarly journals Lifestyle Medicine Interventions in Patients With Advanced Disease Receiving Palliative or Hospice Care

2019 ◽  
Vol 14 (3) ◽  
pp. 243-257 ◽  
Author(s):  
Gowri Anandarajah ◽  
Haran Asher Mennillo ◽  
Gregory Rachu ◽  
Tyler Harder ◽  
Jyotsna Ghosh
Keyword(s):  
Clinical Decision Making ◽  
Hospice Care ◽  
Clinical Decision ◽  
Clear Understanding ◽  
Lifestyle Interventions ◽  
Lifestyle Medicine ◽  
Expert Opinions ◽  
Improve Symptom ◽  
Research Findings ◽  
Available Information

Background: Lifestyle medicine interventions have the potential to improve symptom management, daily function, and quality of life (QOL) in patients with advanced or terminal disease receiving palliative or hospice care. The goal of this review is to summarize the current state of the literature on this subject. Methods: The authors used a broad search strategy to identify relevant studies, reviews, and expert opinions, followed by narrative summary of available information. Results: Four main categories of lifestyle interventions feature prominently in the palliative care literature: exercise, nutrition, stress management, and substance use. High-quality studies in this vulnerable population are relatively sparse. Some interventions show promise. However, most show mixed results or inadequate evidence. For some interventions, risks in this generally frail population outweigh the benefits. Clinical decision making involves balancing research findings, including the risks and benefits of interventions, with a clear understanding of patients’ prognosis, goals of care, and current physical, emotional, and spiritual state. Achieving optimum QOL, safety, and ethical care are emphasized. Conclusions: The use of lifestyle interventions in patients receiving palliative or hospice care is a complex undertaking, requiring tailoring recommendations to individual patients. There is potential for considerable benefits; however, more research is needed.

scholarly journals A Comparison of Physicians' and Nurse Practitioners' Use of Race in Clinical Decision-Making

2019 ◽  
Vol 29 (1) ◽  
pp. 1-8
Author(s):  
Khadijah E. Abdallah ◽  
Kathleen A. Calzone ◽  
Jean F. Jenkins ◽  
Melissa E. Moss ◽  
Sherrill L. Sellers ◽  
...  
Keyword(s):  
Internal Medicine ◽  
Primary Care ◽  
Decision Making ◽  
Genetic Variation ◽  
Nurse Practitioners ◽  
Clinical Decision Making ◽  
Clinical Decision ◽  
Primary Care Providers ◽  
Care Providers ◽  
General Internal

Objective: The debate over use of race as a proxy for genetic risk of disease continues, but little is known about how primary care providers (nurse practitioners and general internal medicine physicians) currently use race in their clinical practice. Our study in­vestigates primary care providers’ use of race in clinical practice.Methods: Survey data from three cross-sectional parent studies were used. A total of 178 nurse practitioners (NPs) and 759 general internal medicine physicians were included. The outcome of interest was the Racial At­tributes in Clinical Evaluation (RACE) scale, which measures explicit use of race in clinical decision-making. Predictor variables included the Genetic Variation Knowledge Assessment Index (GKAI), which measures the providers’ knowledge of human genetic variation.Results: In the final multivariable model, NPs had an average RACE score that was 1.60 points higher than the physicians’ score (P=.03). The GKAI score was not significantly associated with the RACE outcome in the final model (P=.67).Conclusions: Physicians had more knowl­edge of genetic variation and used patients’ race less in the clinical decision-making process than NPs. We speculate that these differences may be related to differences in discipline-specific clinical training and approaches to clinical care. Further explora­tion of these differences is needed, including examination of physicians’ and NPs’ beliefs about race, how they use race in disease screening and treatment, and if the use of race is contributing to health care dispari­ties.Ethn Dis.2019;29(1):1-8; doi:10.18865/ ed.29.1.1.

Why Machine Learning Should Be Taught in Medical Schools (Preprint)

2021 ◽  
Author(s):  
Matthew Nagy ◽  
Nathan Radakovich ◽  
Aziz Nazha
Keyword(s):  
Machine Learning ◽  
Decision Making ◽  
Clinical Decision Making ◽  
Rapid Development ◽  
Clinical Care ◽  
Clinical Decision ◽  
Medical Schools ◽  
Medical Workforce ◽  
Ethical Concerns ◽  
Clinical Tools

UNSTRUCTURED The rapid development of machine learning (ML) applications in healthcare promises to transform the landscape of healthcare. In order for ML advancements to be effectively utilized in clinical care, it is necessary for the medical workforce to be prepared to handle these changes. As physicians in training are exposed to a wide breadth of clinical tools during medical school, this offers an ideal opportunity to introduce ML concepts. A foundational understanding of ML will not only be practically useful for clinicians, but will also address ethical concerns for clinical decision making. While select medical schools have made effort to integrate ML didactics and practice into their curriculum, we argue that foundational ML principles should be taught to broadly to medical students across the country.

The Effects of Clinical Decision Making on Nurse Practitioners’ Clinical Productivity

2000 ◽  
Vol 23 (3) ◽  
pp. 284-304 ◽  
Author(s):  
Neale R. Chumbler ◽  
Jack M. Geller ◽  
Andrew W. Weier
Keyword(s):  
Decision Making ◽  
Nurse Practitioners ◽  
Clinical Decision Making ◽  
Clinical Decision ◽  
Demographic Characteristics ◽  
Policy Implications ◽  
Group Practice ◽  
Full Time ◽  
Specialty Area ◽  
Primary Practice

The degree of clinical decision making and clinical productivity among nurse practitioners (NPs) is of great interest to policy makers and planners involved in providing appropriate outpatient primary care services. The authors performed a statewide mailed survey of all NPs practicing either full-time or part-time in Wisconsin (response rate of 72.1%) to address the following research questions: Do the demographic characteristics, practice attributes, and primary practice settings of NPs impact their level of clinical decision making (e.g., the autonomy to order laboratory and radiological tests or to refer a patient to a physician specialist other than their collaborating physician)? Do NPs’ levels of clinical decision making correlate with their outpatient clinical productivity, adjusting for demographic characteristics, practice attributes, and primary practice settings? The multiple linear regression results indicated that having more years in practice as an NP, practicing in the family specialty area (vs. a combined other category, which included pediatrics, acute care, geriatrics, neonatal, and school), treating patients according to clinical guidelines, practicing in settings with a fewer number of physicians, and practicing in a multispecialty group practice versus a single-specialty group practice were associated with greater levels of clinical decision making. However, NPs who primarily practiced in a hospital/facility-based practice, as compared with a single-specialty group practice, had lower levels of clinical decision making. After adjusting for demographic characteristics, practice attributes, and primary practice settings, NPs with greater clinical decision-making authority had greater outpatient clinical productivity. The conclusions discuss the policy implications of the findings.

Clinical Epidemiology

2016 ◽  
pp. 285-290
Author(s):  
Scott C. Litin ◽  
John B. Bundrick
Keyword(s):  
Diagnostic Test ◽  
Diagnostic Tests ◽  
Clinical Decision Making ◽  
Clinical Epidemiology ◽  
Clinical Decision ◽  
Test Results ◽  
Specific Patient ◽  
Predictive Values ◽  
Test Sensitivity ◽  
Sensitivity Specificity

Diagnostic tests are tools that either increase or decrease the likelihood of disease. The sensitivity, specificity, and predictive values of normal and abnormal test results can be calculated with even a limited amount of information. Some physicians prefer interpreting diagnostic test results by using the likelihood ratio. This ratio takes properties of a diagnostic test (sensitivity and specificity) and makes them more helpful in clinical decision making. It helps the clinician determine the probability of disease in a specific patient after a diagnostic test has been performed.

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