Moving From Evidence To Decisions in Guidelines: An Analysis of Guidance Documents

Background The process of moving from evidence to decisions (EtD) represents a cornerstone within guideline development methods. Little is known about the processes used by organizations in charge of guideline development and what criteria they consider when formulating recommendations. Objective To identify and describe the processes suggested for the formulation of healthcare recommendations in health care guidelines available in guidance documents. Methods We searched in spring 2020 the Guidelines International Network (G-I-N) website, MEDLINE, and The Cochrane Methodology Register to retrieve guidance documents published in the last decade by organizations dedicated to guideline development. Pairs of researchers independently selected and extracted data about the characteristics of the guidance document, including explicit or implicit recommendation-related criteria and processes considered, as well as the use of frameworks. We conducted both descriptive and bivariate analyses. Results We included 68 guidance documents, published mostly by scientific societies (58%). Most of the organizations reported a system for grading the strength of recommendations (88%), half of them being the GRADE approach. Two out of three guidance documents (66%) proposed the use of a framework to guide the EtD process. We identified 14 recommendation-related criteria. The GRADE Evidence to Decision (GRADE-EtD) framework was the most often reported framework (19 organizations, 42%), whereas 20 organizations (44%) proposed their own multi-criteria frameworks. Using any EtD framework was related with a more comprehensive set of recommendation-related criteria compared to no framework, especially for criteria like values, equity, and acceptability. A similar association was observed between the GRADE-EtD framework and either no framework or another EtD frameworks. Conclusion The use of systematic and structured processes for moving from evidence to decisions is still limited among international organizations. The use of EtD frameworks facilitates the inclusion of relevant recommendation criteria. Among the structured frameworks, the GRADE-EtD framework offers the most comprehensive perspective for evidence-informed decision-making processes. More complete and detailed reporting in the guidance documents is warranted.

FERRAMENTA DE APOIO AOS COMANDANTES DAS OPERAÇÕES DE SOCORRO EM INTERVENÇÕES ESTRUTURAIS DAS EQUIPAS DE BOMBEIROS

In a scenario of structural intervention situation, the On-Scene Commanders (COS) only have at their disposal the data provided by the one who gave the alert, which are insufficient to provide a secure and informed decision-making. Through a quantitative, descriptive, observational, and cross-sectional research, using a questionnaire applied to operational staff who perform the COS function, results a survey of the COS information needs. According to the results, it is concluded that the purpose of knowing the risks and outlining a more effective, faster and safer combat strategy for operational personnel involved, could be compromised by the limited information available. A proposal for a new support tool for COS function - the Initial Intervention Plan (PII) - was developed, which is a document of quick and intuitive consultation, supplying the needs of information for COS.

Informed Decision Making on the Uptake of Evidence-Based Smoking Cessation Assistance by Individuals Motivated to Quit Smoking

Evidence-based cessation assistance increases cessation rates. Activating preferences during decision making could improve effectiveness further. Decision aids (DAs) facilitate deciding by taking preferences into account. To develop effective DAs, potential end users' (i.e., individuals motivated to quit) needs and experts' viewpoints should be considered. Therefore, the aim of this needs assessment was: (1) To explore end users' needs and (2) to obtain consensus among smoking cessation counsellors and scientific experts to develop a self-administered DA to support end users in choosing cessation assistance. Data was gathered via two approaches: (1) twenty semi-structured interviews with potential end users and (2) two three-round Delphi studies with 61 counsellors and 44 scientific experts. Interview data and the first Delphi rounds were analysed qualitatively, the other Delphi rounds were analysed quantitatively. Potential end users acquired information in different ways, e.g., via own experiences. Important characteristics to decide between tools varied, however effectiveness and costs were commonly reported. Experts reached consensus on 38 and 40 statements, e.g., tools should be appropriate for users' addiction level. Although some trends emerged, due to the variation among stakeholders, a 'one size fits all'-approach is undesirable. This heterogeneity should be considered, e.g., by enabling users to customise the DA.

Facilitators and Barriers to Implementing a Digital Informed Decision Making Tool in Primary Care: A Qualitative Study

Background Informed decision aids provide information in the context of the patient's values and improve informed decision making (IDM). To overcome barriers that interfere with IDM, our team developed an innovative iPad-based application (aka “app”) to help patients make informed decisions about colorectal cancer screening. The app assesses patients' eligibility for screening, educates them about their options, and empowers them to request a test via the interactive decision aid. Objective The aim of the study is to explore how informed decision aids can be implemented successfully in primary care clinics, including the facilitators and barriers to implementation; strategies for minimizing barriers; adequacy of draft training materials; and any additional support or training desired by clinics. Design This work deals with a multicenter qualitative study in rural and urban settings. Participants A total of 48 individuals participated including primary care practice managers, clinicians, nurses, and front desk staff. Approach Focus groups and semi-structured interviews, with data analysis were guided by thematic analysis. Key Results Salient emergent themes were time, workflow, patient age, literacy, and electronic health record (EHR) integration. Saving time was important to most participants. Patient flow was a concern for all clinic staff, and they expressed that any slowdown due to patients using the iPad module or perceived additional work to clinic staff would make staff less motivated to use the program. Participants voiced concern about older patients being unwilling or unable to utilize the iPad and patients with low literacy ability being able to read or comprehend the information. Conclusion Integrating new IDM apps into the current clinic workflow with minimal disruptions would increase the probability of long-term adoption and ultimate sustainability. NIH trial registry number R01CA218416-A1.

Bell v Tavistock: Rethinking informed decision-making as the practical device of consent for medical treatment

The decision of the High Court in Bell v Tavistock has excited considerable discussion about lawful consent for puberty-blocking drug treatment for children with gender dysphoria. The present paper draws attention to a wider question that surfaces through this case: is informed decision-making an adequate practical tool for seeking and obtaining patients’ consent for medical treatment? Informed decision-making engages the premises of the rational choice theory: that people will have well-crystallised health goals; and, if they are provided with sufficient information about medical treatments, then they will be able to choose the treatment that satisfies their goals. Whilst appealing, the informed decision-making paradigm is assailed by various fallacies, which apply not only to children but also to adults. In Bell v Tavistock, the High Court seems to have recognised such fallacies, and it rejected informed decision-making as an adequate tool for consent from children with gender dysphoria. Similar considerations apply to adults in various situations. Thus, Bell v Tavistock can be seen as an attempt to refine the views on the consent that were expressed by the Supreme Court in Montgomery. It can be inferred that the Supreme Court did recognise the limitations of informed decision-making, but it did not develop this point. Further work is required to formulate an adequate model of decision-making, and Bell v Tavistock serves as a useful reminder to rethink informed decision-making as the device for consent.

Mobile Audio Recording Technology to Promote Informed Decision Making in Advanced Prostate Cancer

PURPOSE Men with metastatic castration-resistant prostate cancer increasingly encounter complex treatment decisions. Consultation audio recordings and summaries promote patient informed decision making but are underutilized. Mobile recording software applications may increase access. Little is known regarding the feasibility of implementation in clinical encounters. METHODS We conducted a mixed-methods pilot study in men with progressive metastatic castration-resistant prostate cancer. We instructed patients to use a mobile software application to record an oncology visit. Patients could share the recording with our patient scribing program to receive a written summary. We assessed feasibility and acceptability with postvisit surveys. We measured patient-reported helpfulness of the intervention in decision making and change in Decisional Conflict Scale–informed subscale. We conducted semistructured interviews to explore implementation and analyzed transcripts using thematic analysis. RESULTS Across 20 patients, 18 (90%) recorded their visits. Thirteen of 18 (72%) listened to the recording, and 14 of 18 (78%) received a summary. Eighteen of 20 (90%) visits were telehealth. Fourteen patients (70% of all 20; 78% of 18 question respondents) found the application easy to use. Nine patients (50% of 18 recording patients; 90% of 10 question respondents) reported that the recording helped treatment decision making. Decisional conflict decreased from baseline to 1-week postvisit (47.4-28.5, P < .001). Interviews revealed benefits, facilitators, contextual factors, and technology and patient-related barriers to recordings and summaries. CONCLUSION In this single-institution academic setting, a mobile application for patients to record consultations was a feasible, acceptable, and potentially valued intervention that improved decision making in the telehealth setting. Studies in larger, diverse populations are needed.

Understanding Patients’ and Living Donors’ Kidney Paired Donation Educational Experiences and Recommendations for Improvement

Introduction Educating potential kidney patients and living donors about the risks and benefits of kidney paired donation to ensure they make informed decisions is complex. This study aimed to increase understanding of patients’ and donors’ decision-making about donation, the educational content they received, and their recommendations for educational improvements. Method We conducted a mixed methods study, including semistructured interviews and quantitative surveys, with 43 participants (25 living donors; 18 kidney recipients). Findings Participants reported that the benefits of paired donation motivated them to participate (ie, helping multiple people, receiving a transplant sooner, flexible timing of donation). Although deciding to participate in paired donation was a systematic, logical, and carefully considered process for some. For most, it was a quickly made, often emotion-based decision. Paired donation educational content on different topics varied, with recipients reporting receiving less information than donors about donor protections and processes to ameliorate the challenges faced, such as broken swaps and chains, and delays in matching. Those who faced challenges requested more information about donor protections and support during and after paired donation. Although many acknowledged their transplant coordinators’ helpfulness, participants also recommended being more proactive in learning about kidney paired donation and speaking to former donors and recipients beforehand. Discussion Standardized, health literate educational content addressing the gaps and variability in education received may help increase paired donation informed decision-making.

Rapid reviews as an emerging approach to evidence synthesis in education

Rapid reviews using abbreviated systematic review methods are of increasing importance for evidence-informed decision-making in education, although there is little guidance about the most suitable approach. Three recently completed rapid review reports are compared to inform discussions on the utility of this type of review in education and to highlight appropriate methods for producing evidence syntheses in a limited time frame. Rapid review methods need to be chosen to fit the needs of the review, which involves: thinking broadly about different kinds of team experience and expertise; estimating the size and nature of the literature to be reviewed; considering the review purpose and nature of the topic; choosing an appropriate synthesis method for the review purpose, evidence base and reviewers’ expertise; fully describing the review approach, and discussing the potential limitations of chosen methods; and understanding the anticipated audiences and tailoring outputs accordingly. Rapid reviews to address urgent and high-priority questions provide the benefits of timeliness and reduced resource requirements. However, it is crucial to understand caveats and limitations to the rapid conduct of evidence syntheses for decision-making purposes. This article offers guidance to support researchers, postgraduate students and commissioners who wish to conduct rapid reviews in a transparent and systematic way, addressing complex questions of relevance to evidence-informed decision-making in education.