Application of analytic hierarchy process for measuring and comparing the global performance of intensive care units

Analytic hierarchy process: An innovative technique for culturally tailoring evidence-based interventions to reduce health disparities

Latinos in the United States represent a disproportionate burden of illness and disease and face barriers to accessing health care and related resources. Culturally tailored, evidence-based interventions hold promise in addressing many of these challenges. Yet, ensuring patient voice is vital in the successful development and implementation of such interventions. Thus, this paper examines the application of analytic hierarchy process (AHP) to inform the augmentation and implementation of an evidence-based chronic disease self-management programme for underserved Latinos living with both minor depression and chronic illness. The process of AHP allows for direct input from the individuals that would utilize such a programme, including afflicted individuals, their family members and the health educators/promotores that would be responsible for implementation. Specifically, 45 participants, including 15 individuals with chronic disease, 15 family members/caregivers and 15 promotores, partook in the Stakeholder Values Questionnaire, which elicited preferences and values regarding major goals, processes and content for the intervention. AHP was employed to analyse pairwise comparison ratings and to determine differences and similarities across stakeholder groups. This analytical technique allowed for the adaptation of the EBI to stakeholders' specific priorities and preferences and facilitated complex decision-making. Findings not only shed light on similarities and differences between stakeholder groups, but also the magnitude of these priorities and preferences and allowed the intervention to be driven by the participants, themselves. Applying AHP was a unique opportunity to optimize the decision-making process to inform cultural adaptation of an EBI while considering multiple viewpoints systematically.

Prioritizing Community-Based Intervention Programs for Improving Treatment Compliance of Patients with Chronic Diseases: Applying an Analytic Hierarchy Process

The purpose of this study was to apply multicriteria decision making and an analytic hierarchy process (AHP) model for assessing sustainable management of hypertension and diabetes. Perception of two alternative health care priorities was also investigated. One priority was improving treatment compliance of patients with hypertension and diabetes. The other priority was strengthening the healthcare system for continuous care. Our study design to evaluate community-based intervention programs for hypertension and diabetes was developed using brainstorming, Delphi techniques, and content analysis along with literature review. We finally proposed a hierarchical structure of the AHP model with 50 third sub-criteria in six levels. By surveying this AHP questionnaire to a total of 185 community health practitioners in Korea, we found that improving treatment compliance of patients with chronic diseases should be relatively more important than strengthening the healthcare system. Further research is needed to expand survey subjects to primary care physicians and even policymakers of central government for the appropriate application of this AHP model.

Continuous quality improvement in a Maltese hospital using logical framework analysis

Purpose

The purpose of this paper is to present the application of logical framework analysis (LFA) for implementing continuous quality improvement (CQI) across multiple settings in a tertiary care hospital.

Design/methodology/approach

This study adopts a multiple case study approach. LFA is implemented within three diverse settings, namely, intensive care unit, surgical ward, and acute in-patient psychiatric ward. First, problem trees are developed in order to determine the root causes of quality issues, specific to the three settings. Second, objective trees are formed suggesting solutions to the quality issues. Third, project plan template using logical framework (LOGFRAME) is created for each setting.

Findings

This study shows substantial improvement in quality across the three settings. LFA proved to be effective to analyse quality issues and suggest improvement measures objectively.

Research limitations/implications

This paper applies LFA in specific, albeit, diverse settings in one hospital. For validation purposes, it would be ideal to analyse in other settings within the same hospital, as well as in several hospitals. It also adopts a bottom-up approach when this can be triangulated with other sources of data.

Practical implications

LFA enables top management to obtain an integrated view of performance. It also provides a basis for further quantitative research on quality management through the identification of key performance indicators and facilitates the development of a business case for improvement.

Originality/value

LFA is a novel approach for the implementation of CQI programs. Although LFA has been used extensively for project development to source funds from development banks, its application in quality improvement within healthcare projects is scant.

Multicriteria decision analysis in oncology

BACKGROUND

There has been a growing interest in the development and application of alternative decision-making frameworks within health care, including multicriteria decision analysis (MCDA). Even though the literature includes several reviews on MCDA methods, applications of MCDA in oncology are lacking.

AIM

The aim of this paper is to discuss a rationale for the use of MCDA in oncology. In this context, the following research question emerged: How can MCDA be used to develop a clinical decision support tool in oncology?

METHODS

In this paper, a brief background on decision making is presented, followed by an overview of MCDA methods and process. The paper discusses some applications of MCDA, proposes research opportunities in the context of oncology and presents an illustrative example of how MCDA can be applied to oncology.

FINDINGS

Decisions in oncology involve trade-offs between possible benefits and harms. MCDA can help analyse trade-off preferences. A wide range of MCDA methods exist. Each method has its strengths and weaknesses. Choosing the appropriate method varies depending on the source and nature of information used to inform decision making. The literature review identified eight studies. The analytical hierarchy process (AHP) was the most often used method in the identified studies.

CONCLUSION

Overall, MCDA appears to be a promising tool that can be used to assist clinical decision making in oncology. Nonetheless, field testing is desirable before MCDA becomes an established decision-making tool in this field.

Application of pediatric index of mortality version 2: score in pediatric intensive care unit in an African developing country

Introduction

Outcome of patients admitted to PICU can be evaluated by many illness severity scoring systems. This prospective observational study evaluated the outcome of patients admitted to PICU in Fayoum University hospital of a developing country using the pediatric index of mortality version 2 scoring system.

Methods

All patients included in this study were subjected to data collection including demographics, diagnoses at admission, duration of ICU stay (DOS), pediatric index of mortality version 2 (PIM2) score and hospital outcome. The ratio of observed to predicted mortality (standardized mortality ratio (SMR)) was calculated for the set of patients.

Results

The study included 205 patients. The main causes of admission were respiratory, cardiovascular and neurological illnesses. Patients stay in ICU ranged from 1 - 45 days with a median 6 (interquartile range (IQ): 3-9) days. Discriminatory function of PIM2 scoring system was acceptable with the area under the ROC curve 0.76 (95%CI: 0.60-0.91). PIM2 calibrated well using Hosmer Lemeshow analysis (H-L X2= 1.410, df= 8, p=0.9). The mean predicted mortality was 5.6 (95% CI: 3.43 - 7.91) and the observed mortality was 8.8% giving a SMR 1.55.

Conclusion

PIM2 scoring system show adequate discriminatory function and well calibrated for the case mix of patients in PICU of Fayoum, Egypt. It can be used as beneficial tool for evaluation of risk adjusted mortality. Further larger scale studies in cooperation with other Egyptian universities and neighboring countries can improve the performance of our PICUs and critical care services.

Intensive care units in Turkish hospitals: do they meet the minimum standards?

BACKGROUND

International and national standards for ICUs have been developed to ensure patient safety and provide effective and efficient service in these units. However, global economic crises along with shortages in professional health care staff affect the ability of ICUs to meet and maintain these standards.

AIMS AND OBJECTIVES

The aim of this study was to ascertain whether the equipment and workforce in intensive care units (ICUs) in Turkish hospitals meet current ICU standards.

DESIGN

This is a descriptive study based on the results of a survey questionnaire.

METHODS

In total, 145 ICUs in university and private hospitals in Turkey participated in this survey. Data collection was done by means of a survey questionnaire that assessed the current equipment and workforce in these ICUs.

RESULTS

We found that 97·0% of the occupied beds in the ICUs had a cardiac monitor. Crash-carts were present in every ICU. Transport monitors and transport ventilators were available in two of three and in one of two ICUs, respectively. In 82·8% of the ICUs, a physician (as a trainee level) was present at all times, while only a few ICUs had ICU-care team members such as respiratory- and physiotherapist, clinical pharmacists and dieticians available. There was a general shortage of nursing staff in ICUs.

CONCLUSION

Currently, ICUs in Turkish hospitals meet the majority of standards for ICU equipment, but they fail to meet both the international and national standards for ICU workforce requirement.

CLINICAL RELEVANCE

Hospital and ICU managers could use our findings to compare their facilities with others or to identify areas in need of improvement.

Validation of Pediatric Index of Mortality-2 scoring system in a pediatric intensive care unit, Barbados

This study evaluated the outcome of patients in a pediatric intensive care unit (ICU) of a developing country applying Pediatric Index of Mortality (PIM) version-2 scoring system. A total of 163 consecutive patients were prospectively studied. Data included demographics, diagnoses at admission, PIM-2 score, the duration of ICU stay and hospital outcome. Predicted mortality and standardized mortality ratio (SMR) were calculated. Respiratory and neurological illnesses were the main admission diagnoses. The mean length of stay was 5.4 [95% Confidence Intervals (CI): 4-6.9] days. The mean predicted mortality was 6.2% (95% CI: 4.3-8.1); the observed mortality rate was 5.5%, the SMR being 0.89. Hosmer-Lemeshow analysis calibrated PIM-2 for the case mix [χ(2) = 5.64 (df = 7), p = 0.58]. The area under the ROC curve was 0.82 (95% CI: 0.72-0.92) showing a good discriminant function. Performance of the pediatric ICU in Barbados is comparable to that of developed world by risk-adjusted outcome evaluation.

Shared decision-making--transferring research into practice: the Analytic Hierarchy Process (AHP)

OBJECTIVE

To illustrate how the Analytic Hierarchy Process (AHP) can be used to promote shared decision-making and enhance clinician-patient communication.

METHODS

Tutorial review.

RESULTS

The AHP promotes shared decision-making by creating a framework that is used to define the decision, summarize the information available, prioritize information needs, elicit preferences and values, and foster meaningful communication among decision stakeholders.

CONCLUSIONS

The AHP and related multi-criteria methods have the potential for improving the quality of clinical decisions and overcoming current barriers to implementing shared decision-making in busy clinical settings. Further research is needed to determine the best way to implement these tools and to determine their effectiveness.

PRACTICE IMPLICATIONS

Many clinical decisions involve preference-based trade-offs between competing risks and benefits. The AHP is a well-developed method that provides a practical approach for improving patient-provider communication, clinical decision-making, and the quality of patient care in these situations.

Relationship between risk information on total colonoscopy and patient preferences for colorectal cancer screening options: analysis using the analytic hierarchy process

BACKGROUND

Although the fecal occult blood test (FOBT) is the preferred program for colorectal cancer screening in Japan, many medical institutions have recently begun to provide total colonoscopy (TCS) as an initial screening program. However, there are a number of severe risks associated with TCS, such as colorectal bleeding and perforation. The justification for performing such a procedure on healthy patients remains unclear. We used the analytic hierarchy process (AHP) to investigate whether risk information on TCS affects patient preferences for colorectal cancer screening.

METHODS

We performed a questionnaire survey using an AHP decision-making model, targeting 285 people aged 40-59 years. We randomly assigned the subjects into Groups A (n = 146) and B (n = 139). Both groups were provided with information on the effectiveness, cost and disadvantages of the two screening programs. Group A was provided with additional information regarding the risks of TCS. Individual priorities were calculated with pair-wise comparisons between the two alternatives in each selection criteria. The influence of the risk information was analyzed using a logistic regression analysis.

RESULTS

The aggregated priorities in Group A for 'effectiveness', 'costs', and 'risks' were 0.603, 0.147, and 0.250, respectively, while those in Group B were 0.652, 0.149, and 0.199, respectively. A logistic regression analysis showed that the provision of risk information significantly reduced the subjects' priorities for TCS (p = 0.036).

CONCLUSION

The lack of risk information was related to the differences in priorities assigned to effectiveness and risks of the two procedures. Patients must be well informed before making decisions concerning their preferred colorectal cancer screening procedure.

The use of the analytic hierarchy process to aid decision making in acquired equinovarus deformity

OBJECTIVE

To increase the transparency of decision making about treatment in patients with equinovarus deformity poststroke.

DESIGN

The analytic hierarchy process (AHP) was used as a structured methodology to study the subjective rationale behind choice of treatment.

SETTING

An 8-hour meeting at a centrally located rehabilitation center in The Netherlands, during which a patient video was shown to all participants (using a personal computer and a large screen) and the patient details were provided on paper.

PARTICIPANTS

A panel of 10 health professionals from different backgrounds.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The performance of the applicable treatments on outcome, impact, comfort, cosmetics, daily effort, and risks and side effects of treatment, as well as the relative importance of criteria in the choice of treatment.

RESULTS

According to the model, soft-tissue surgery (.413) ranked first as the preferred treatment, followed by orthopedic footwear (.181), ankle-foot orthosis (.147), surface electrostimulation (.137), and finally implanted electrostimulation (.123). Outcome was the most influential consideration affecting treatment choice (.509), followed by risk and side effects (.194), comfort (.104), daily effort (.098), cosmetics (.065), and impact of treatment (.030).

CONCLUSIONS

Soft-tissue surgery was judged best on outcome, daily effort, comfortable shoe wear, and cosmetically acceptable result and was thereby preferred as a treatment alternative by the panel in this study. In contrast, orthosis and orthopedic footwear are usually preferred in daily practice. The AHP method was found to be suitable methodology for eliciting subjective opinions and quantitatively comparing treatments in the absence of scientific evidence.

A unified definition of clinical resistance/intolerance to hydroxyurea in essential thrombocythemia: results of a consensus process by an international working group

A widely accepted definition of resistance or intolerance to hydroxyurea (HU) in patients with essential thrombocythemia (ET) is lacking. An international working group (WG) was convened to develop a consensus formulation of clinically significant criteria for defining resistance/intolerance to HU in ET. To this aim, an analytic hierarchy process (AHP), a multiple-attribute decision-making technique, was used. The steps consisted of selecting the candidate criteria for defining resistance/intolerance; identifying the motivations that could influence the preference of the WG for any individual criterion; comparing the candidate criteria in a pair-wise manner; and grading them according their ability to fulfill the motivations. Every step in the model was derived by questionnaires or group discussion. The WG proposed that the definition of resistance/intolerance should require the fulfillment of at least one of the following criteria: platelet count greater than 600,000/micro l after 3 months of at least 2 g/day of HU (2.5 g/day in patients with a body weight over 80 kg); platelet count greater than 400,000/micro l and WBC less than 2500/micro l or Hb less than 10 g/dl at any dose of HU; presence of leg ulcers or other unacceptable muco-cutaneous manifestations at any dose of HU; HU-related fever.

Extending basic principles of measurement models to the design and validation of Patient Reported Outcomes

A recently published article by the Scientific Advisory Committee of the Medical Outcomes Trust presents guidelines for selecting and evaluating health status and health-related quality of life measures used in health outcomes research. In their article, they propose a number of validation and performance criteria with which to evaluate such self-report measures. We provide an alternate, yet complementary, perspective by extending the types of measurement models which are available to the instrument designer. During psychometric development or selection of a Patient Reported Outcome measure it is necessary to determine which, of the five types of measurement models, the measure is based on; 1) a Multiple Effect Indicator model, 2) a Multiple Cause Indicator model, 3) a Single Item Effect Indicator model, 4) a Single Item Cause Indicator model, or 5) a Mixed Multiple Indicator model. Specification of the measurement model has a major influence on decisions about item and scale design, the appropriate application of statistical validation methods, and the suitability of the resulting measure for a particular use in clinical and population-based outcomes research activities.