More options, more considerations: how new treatment options influence clinical decision making

Open surgical repair of lesions of the descending thoracic aorta, such as aneurysm, dissection and traumatic rupture, has been the state-of-the-art treatment for many decades. However, in specialized cardiovascular centers, thoracic endovascular aortic repair and hybrid aortic procedures have been implemented as novel treatment options. The current clinical results show that these procedures can be performed with low morbidity and mortality rates. However, due to a lack of randomized trials, the level of reliability of these new treatment modalities remains a matter of discussion. Clinical decision-making is generally based on the experience of the vascular center as well as on individual factors, such as life expectancy, comorbidity, aneurysm aetiology, aortic diameter and morphology. This article will review and discuss recent publications of open surgical, hybrid thoracic aortic (in case of aortic arch involvement) and endovascular repair in complex pathologies of the descending thoracic aorta.

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The ‘Number Needed to Treat’ and the ‘Adjusted NNT’ in Health Care Decision-Making

Journal of Health Services Research & Policy ◽

10.1177/135581969800300110 ◽

1998 ◽

Vol 3 (1) ◽

pp. 44-49 ◽

Cited By ~ 9

Author(s):

Jack Dowie

Keyword(s):

Health Care ◽

Decision Making ◽

Evidence Based Medicine ◽

Clinical Decision Making ◽

Treatment Options ◽

Clinical Decision ◽

Population Based ◽

Number Needed To Treat ◽

Evidence Based ◽

Based Medicine

Within ‘evidence-based medicine and health care’ the ‘number needed to treat’ (NNT) has been promoted as the most clinically useful measure of the effectiveness of interventions as established by research. Is the NNT, in either its simple or adjusted form, ‘easily understood’, ‘intuitively meaningful’, ‘clinically useful’ and likely to bring about the substantial improvements in patient care and public health envisaged by those who recommend its use? The key evidence against the NNT is the consistent format effect revealed in studies that present respondents with mathematically-equivalent statements regarding trial results. Problems of understanding aside, trying to overcome the limitations of the simple (major adverse event) NNT by adding an equivalent measure for harm (‘number needed to harm’ NNH) means the NNT loses its key claim to be a single yardstick. Integration of the NNT and NNH, and attempts to take into account the wider consequences of treatment options, can be attempted by either a ‘clinical judgement’ or an analytical route. The former means abandoning the explicit and rigorous transparency urged in evidence-based medicine. The attempt to produce an ‘adjusted’ NNT by an analytical approach has succeeded, but the procedure involves carrying out a prior decision analysis. The calculation of an adjusted NNT from that analysis is a redundant extra step, the only action necessary being comparison of the results for each option and determination of the optimal one. The adjusted NNT has no role in clinical decision-making, defined as requiring patient utilities, because the latter are measurable only on an interval scale and cannot be transformed into a ratio measure (which the adjusted NNT is implied to be). In any case, the NNT always represents the intrusion of population-based reasoning into clinical decision-making.

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Clinical Decision Making on Extensive Molar Restorations

Operative Dentistry ◽

10.2341/13-069-c ◽

2014 ◽

Vol 39 (6) ◽

pp. E231-E240 ◽

Cited By ~ 11

Author(s):

T Laegreid ◽

NR Gjerdet ◽

A Johansson ◽

A-K Johansson

Keyword(s):

Decision Making ◽

Clinical Decision Making ◽

Dietary Habits ◽

Influencing Factor ◽

Treatment Options ◽

Clinical Decision ◽

Background Information ◽

Molar Teeth ◽

Logistic Regressions ◽

Indirect Technique

SUMMARY Extensive loss of posterior tooth substance, which traditionally was restored with amalgam or indirect restorations, is more commonly being restored with resin-based composite restorations. Using a questionnaire, we aimed to survey dentists' clinical decision making when restoring extensive defects in posterior molar teeth. The questionnaire, which included questions on background information from the dentists, clinical cases with treatment options, and general questions about restoring extensive posterior defects, was sent to 476 dentists. The response rate was 59%. Multiple logistic regressions were used to investigate the different associations. Most of the respondents preferred a direct composite restoration when one cusp was missing, while indirect restorations were most preferred when replacing three or four cusps. Younger dentists and dentists working in the private sector had a greater tendency to choose an indirect technique compared with older colleagues. Generally, the most important influencing factor in clinical decision making was the amount of remaining tooth substance. Factors that appeared to be less important were dental advertisements, use of fluoride, and dietary habits. Female dentists perceived factors such as oral hygiene, patient requests, and economy to be more important than did their male colleagues.

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Exploring patient satisfaction of a joint-consultation clinic for trigeminal neuralgia: Enabling improved decision-making

British Journal of Pain ◽

10.1177/20494637211045877 ◽

2021 ◽

pp. 204946372110458

Author(s):

Jolyon Poole ◽

Valeria Mercadante ◽

Sanjeet Singhota ◽

Karim Nizam ◽

Joanna M Zakrzewska

Keyword(s):

Decision Making ◽

Trigeminal Neuralgia ◽

Clinical Decision Making ◽

Response Rate ◽

Treatment Options ◽

Rare Condition ◽

Clinical Decision ◽

Consultation Clinic ◽

Level Of Satisfaction ◽

Paper Survey

Background Trigeminal neuralgia (TN) is a relatively rare condition which has a profound impact not only on the patient but also on those around them. There is no cure for TN, and the management of the condition is complex. The most effective forms of treatment are either through medication, neurosurgery, or combination of the two. Each option has risks and implications for the patient. As with all clinical decisions, it is important for patients to understand and be fully informed of the treatments available to them. A London UK unit adopted a joint-consultation clinic approach where the patient meets with both physician and neurosurgeon at the same time to discuss treatment options. The purpose of this evaluation is to understand patients’ level of satisfaction with the joint-consultation clinic and evaluate utilisation of a clinical decision-making tool. Method Patients who had attended the joint-consultation clinic over a period of 12 months were invited to participate in a telephone or paper survey (N = 55). Responses were analysed using descriptive statistics and thematic analysis. Results Forty-one patients (77% response rate) participated in the survey, and the results were overwhelmingly positive for the joint-consultation clinic regarding satisfaction. The benefits were broad ranging including increased understanding, collaboration and confidence in decision-making. Conclusions A joint-consultation clinic comprising a neurosurgeon and a physician for the treatment of TN is valued by patients who become better informed and able to make decisions about their care. Positive application of clinical decision-making aids in this situation offers potential across specialities.

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A 52-Year-Old Man With Progressive Weakness and Incontinence

The Neurohospitalist ◽

10.1177/19418744211039586 ◽

2021 ◽

pp. 194187442110395

Author(s):

Ayse Altintas ◽

Ayca Ersen Danyeli ◽

Subutay Berke Bozkurt ◽

Sanem Pinar Uysal ◽

Sergin Akpek ◽

...

Keyword(s):

Decision Making ◽

Urinary Retention ◽

Clinical Decision Making ◽

Treatment Options ◽

Diagnostic Testing ◽

Clinical Decision ◽

Diagnostic Tools ◽

Progressive Weakness ◽

Over Time

Here we report a challenging case of a 52-year-old man presenting with subacute constipation, urinary retention, impotence, absent Achilles reflexes, and hypoesthesia in S2-S5 dermatomes. We review the clinical decision-making as the symptoms evolved and diagnostic testing changed over time. Once the diagnosis is settled, we discuss the sign and symptoms, additional diagnostic tools, treatment options and prognosis.

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Interactive Video Assists in Clinical Decision Making

Methods of Information in Medicine ◽

10.1055/s-0038-1634516 ◽

1998 ◽

Vol 37 (02) ◽

pp. 201-205 ◽

Cited By ~ 12

Author(s):

B. E. Waitzfelder ◽

E. P. Gramlich

Keyword(s):

Breast Cancer ◽

Decision Making ◽

Interactive Video ◽

Clinical Decision Making ◽

Treatment Options ◽

Treatment Decision ◽

Clinical Decision ◽

Medical Decision ◽

Treatment Decision Making ◽

Interactive Videodisk

AbstractThe Hawaii Quality and Cost Consortium began a project in 1993 to implement and evaluate interactive videodisk programs to assist in clinical decision-making for breast cancer. Communication problems between physicians and patients, limitations of available outcomes data and varying preferences of individual patients can result in treatment outcomes that are less than satisfactory. Shared Decision-making Programs (SDPs) were developed by the Foundation for Informed Medical Decision Making (FIMDM) in Hanover, New Hampshire, to assist in the treatment decision-making process. Utilizing interactive videodisks, the programs provide patients with clear, unbiased information about available treatment options. With this information, patients can become more active participants in making treatment decisions. The SDPs for breast cancer were implemented at two sites in Hawaii. Evaluation data from 103 patients overwhelmingly indicate that patients find the programs clear, balanced and very good or excellent in terms of the amount of information presented and overall rating.

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Partnerships with Patients: The Pros and Cons of Shared Clinical Decision-Making

Journal of Health Services Research & Policy ◽

10.1177/135581969700200209 ◽

1997 ◽

Vol 2 (2) ◽

pp. 112-121 ◽

Cited By ~ 277

Author(s):

Angela Coulter

Keyword(s):

Decision Making ◽

Shared Decision Making ◽

Information Needs ◽

Clinical Decision Making ◽

Treatment Options ◽

Clinical Decision ◽

Treatment Decisions ◽

Medical Decision ◽

Shared Decision ◽

Pros And Cons

The traditional style of medical decision-making in which doctors take sole responsibility for treatment decisions is being challenged. Attempts are being made to promote shared decision-making in which patients are given the opportunity to express their values and preferences and to participate in decisions about their care. Critics of shared decision-making argue that most patients do not want to participate in decisions; that revealing the uncertainties inherent in medical care could be harmful; that it is not feasible to provide information about the potential risks and benefits of all treatment options; and that increasing patient involvement in decision-making will lead to greater demand for unnecessary, costly or harmful procedures which could undermine the equitable allocation of health care resources. This article examines the evidence for and against these claims. There is considerable evidence that patients want more information and greater involvement, although knowledge about the circumstances in which shared decision-making should be encouraged, and the effects of doing so, is sparse. There is an urgent need for more research into patients' information needs and preferences and for the development and evaluation of decision-support mechanisms to enable patients to become informed participants in treatment decisions.

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Basics of Dental Implantology for the Oral Surgeon

Oral and Maxillofacial Surgery for the Clinician ◽

10.1007/978-981-15-1346-6_18 ◽

2021 ◽

pp. 385-405

Author(s):

Supriya Ebenezer ◽

Vinay V. Kumar ◽

Andreas Thor

Keyword(s):

Decision Making ◽

Clinical Decision Making ◽

Clinical Decision ◽

The Other ◽

Oral Surgical Procedures ◽

Implant Placement ◽

Treatment Concepts ◽

Implant Dentistry ◽

New Treatment ◽

Implant Treatment

AbstractOver the past decades, implant dentistry has evolved to be a very predictable treatment modality for the replacement of lost teeth and has now become one of the most common oral surgical procedures carried out worldwide. This chapter introduces the history and evolution of dental implants, discusses the concept of osseointegration, mentions the types of implants and discusses clinical decision making and execution of straight forward implant placement. It must be noted that the field of implantology is rapidly developing with new treatment concepts and increasing use of digital technology. The surgical part of implant treatment although extremely important, is only a part of the overall treatment, the other important factors being the laboratory and prosthodontics. This chapter only provides a basic surgical overview of implantology for the beginner surgeon clinician.

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Second Surgery for Progressive Glioblastoma: A Multi-Centre Questionnaire and Cohort-Based Review of Clinical Decision-Making and Patient Outcomes in Current Practice

10.21203/rs.3.rs-192314/v1 ◽

2021 ◽

Author(s):

Paul Brennan ◽

R Borchert ◽

C Coulter ◽

G Critchley ◽

B Hall ◽

...

Keyword(s):

Decision Making ◽

Patient Outcomes ◽

Clinical Decision Making ◽

Performance Status ◽

Treatment Options ◽

Cohort Analysis ◽

Methylation Status ◽

Clinical Decision ◽

Extent Of Resection ◽

Second Surgery

Abstract PurposeGlioblastoma prognosis is poor. Treatment options are limited at progression. Surgery may benefit, but no quality guidelines exist to inform patient selection. We sought to describe variations in surgical management at progression, highlight where further evidence is needed, and build towards a consensus strategy. MethodsCurrent practice in selection of patients with progressive GBM for second surgery was surveyed online amongst specialists in the UK and Europe. We complemented this with an assessment of practice in a retrospective cohort study from six United Kingdom neurosurgical units. We used descriptive statistics to analyse the data. Results234 questionnaire responses were received. Maintaining or improving patient quality of life was key to decision making, with variation as to whether patient age, performance status or intended extent of resection was relevant. MGMT methylation status was not important. Half considered no minimum time after first surgery. 288 patients were reported in the cohort analysis. Median time to second surgery from first surgery 390 days. Median overall survival 815 days, with no association between time to second surgery and time to death (p=0.874). ConclusionThis is the most wide-ranging examination of contemporaneous practice in management of GBM progression. Without evidence-based guidelines, the variation is unsurprising. We propose consensus guidelines for consideration, to reduce heterogeneity in decision making, support data collection and analysis of factors influencing outcomes, and to inform clinical trials to establish whether second surgery improves patient outcomes, or simply selects to patients already performing well.

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Treatment Options in Oncology

JCO Clinical Cancer Informatics ◽

10.1200/cci.18.00017 ◽

2018 ◽

pp. 1-10 ◽

Cited By ~ 8

Author(s):

Cédric M. Panje ◽

Markus Glatzer ◽

Charlotta Sirén ◽

Ludwig Plasswilm ◽

Paul M. Putora

Keyword(s):

Decision Making ◽

Clinical Decision Making ◽

Medical Condition ◽

Treatment Options ◽

Treatment Strategies ◽

Clinical Decision ◽

Vital Role ◽

Patient Specific ◽

Treatment Preferences ◽

Multiple Treatment

Multiple treatment strategies exist for many oncologic problems. In this review, we provide a summary of various reasons for the existence of multiple treatment options in oncology, including factors that concern the treating physician (eg, treatment preferences), environmental factors (eg, financial, regulatory, and scientific aspects), and individual patient-specific factors (eg, medical condition, preferences). We demonstrate the vital role of available treatment options and their origins for clinical decision making and patient communication. These aspects are particularly helpful in the process of shared decision making, which is increasingly favored in situations where there are multiple medically reasonable options.

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