Many faces of rationality: Implications of the great rationality debate for clinical decision-making

Decision threshold models in medical decision making: a scoping literature review

BACKGROUND

Decision thresholds play important role in medical decision-making. Individual decision-making differences may be attributable to differences in subjective judgments or cognitive processes that are captured through the decision thresholds. This systematic scoping review sought to characterize the literature on non-expected utility decision thresholds in medical decision-making by identifying commonly used theoretical paradigms and contextual and subjective factors that inform decision thresholds.

METHODS

A structured search designed around three concepts-individual decision-maker, decision threshold, and medical decision-was conducted in MEDLINE (Ovid) and Scopus databases from inception to July 2023. ProQuest (Dissertations and Theses) database was searched to August 2023. The protocol, developed a priori, was registered on Open Science Framework and PRISMA-ScR guidelines were followed for reporting on this study. Titles and abstracts of 1,618 articles and the full texts for the 228 included articles were reviewed by two independent reviewers. 95 articles were included in the analysis. A single reviewer used a pilot-tested data collection tool to extract study and author characteristics, article type, objectives, theoretical paradigm, contextual or subjective factors, decision-maker, and type of medical decision.

RESULTS

Of the 95 included articles, 68 identified a theoretical paradigm in their approach to decision thresholds. The most common paradigms included regret theory, hybrid theory, and dual processing theory. Contextual and subjective factors that influence decision thresholds were identified in 44 articles.

CONCLUSIONS

Our scoping review is the first to systematically characterizes the available literature on decision thresholds within medical decision-making. This study offers an important characterization of the literature through the identification of the theoretical paradigms for non-expected utility decision thresholds. Moreover, this study provides insight into the various contextual and subjective factors that have been documented within the literature to influence decision thresholds, as well as these factors juxtapose theoretical paradigms.

Developing multisectoral strategies to promote evidence-based practice in rehabilitation: findings from an end-of-grant knowledge translation symposium

PURPOSE

Following a longitudinal study to understand how evidence-based practice evolves during the initial years of occupational therapy (OT) and physiotherapy (PT) practice, we held an end-of-grant symposium with representatives from education, practice, research, and policy. The objectives were to: (1) elicit feedback on the implications of the study results; and (2) co-develop a list of actionable recommendations for each sector.

METHODS

Qualitative participatory approach. The symposium was held over two half days and consisted of a presentation of study findings, a discussion on the implications of the research for each sector and future recommendations. Discussions were audio recorded, transcribed verbatim and analyzed using qualitative thematic analysis.

RESULTS

The themes related to implications of the longitudinal study included: (1) A need to rethink what evidence-based practice (EBP) really is; (2) How to practice EBP; and (3) The continuing challenge of measuring EBP. The co-development of actionable recommendations resulted in nine strategies.

CONCLUSIONS

This study highlighted how we may collectively promote EBP competencies in future OTs and PTs. We generated sector-specific avenues that may be pursued to promote EBP and argued for the importance of pooling efforts from the four sectors so that we may achieve the intended ethos of EBP.IMPLICATIONS FOR REHABILITATIONThere is a need to revisit the definition of evidence-based practice (EBP) and the traditional 3-circle model in rehabilitation to include a broader conceptualization of what constitutes evidence.We recommend using EBP measures as tools for self-reflection and professional development that can support practitioners to be reflective and accountable evidence-based practitioners.Optimal promotion of EBP competencies in occupational therapists and physiotherapists should rest upon collaborative efforts from the education, practice, research, and policy sectors.

Improving methods of clinical practice guidelines: From guidelines to pathways to fast-and-frugal trees and decision analysis to develop individualised patient care

BACKGROUND

Current methods for developing clinical practice guidelines have several limitations: they are characterised by the "black box" operation-a process with defined inputs and outputs but an incomplete understanding of its internal workings; they have "the integration problem"-a lack of framework for explicitly integrating factors such as patient preferences and trade-offs between benefits and harms; they generate one recommendation at a time that typically are not connected in a coherent analytical framework; and they apply to "average" patients, while clinicians and their patients seek advice tailored to individual circumstances.

METHODS

We propose augmenting the current guideline development method by converting evidence-based pathways into fast-and-frugal decision trees (FFTs) and integrating them with generalised decision curve analysis to formulate clear, individualised management recommendations.

RESULTS

We illustrate the process by developing recommendations for the management of heparin-induced thrombocytopenia (HIT). We converted evidence-based pathways for HIT, developed by the American Society of Hematology, into an FFT. Here, we consider only thrombotic complications and major bleeding. We leveraged the predictive potential of FFTs to compare the effects of argatroban, bivalirudin, fondaparinux, and direct oral anticoagulants (DOACs) using generalised decision curve analysis. We found that DOACs were superior to other treatments if the FFT-predicted probability of HIT exceeded 3%.

CONCLUSIONS

The proposed analytical framework connects guidelines, pathways, FFTs, and decision analysis, offering risk-tailored personalised recommendations and addressing current guideline development critiques.

Patients' attitudes and preferences toward delayed disease progression in the absence of improved survival

BACKGROUND

Cancer patients' attitudes toward progression-free survival (PFS) gains offered by treatment are not well understood, particularly in the absence of overall survival (OS) gains. The objectives were to describe patients' willingness to accept treatment that offers PFS gains without OS gains, to compare these findings with treatments offering OS gains, and to qualitatively summarize patients' reasons for their preferences.

METHODS

A multicenter, cross-sectional, convergent mixed-methods study design recruited patients who had received at least 3 months of systemic therapy for incurable solid tumors. A treatment trade-off exercise determined the gains in imaging PFS that patients require to prefer additional systemic treatment for a scenario of a newly diagnosed, asymptomatic, incurable abdominal tumor. A qualitative, descriptive, thematic analysis explored factors influencing patients' decisions, and a narrative method integrated the quantitative and qualitative findings.

RESULTS

In total, 100 patients participated (63% were older than 60 years of age). If additional treatment with added toxicity offered no OS advantage, 17% would prefer it for no PFS benefit; 26% for some PFS benefit (range, 3-9 months), whereas 51% would decline it regardless of PFS benefit. Similarly, 71% preferred additional treatment offering a 6-month OS advantage dependent on described toxicity levels (P = .03). A spectrum of reasons for these preferences reflected the complexity of participants' attitudes and values.

CONCLUSIONS

Prolongation of time to progression was not universally valued. Most patients did not prefer treatments that negatively affect quality of life for PFS gains alone. Implications for individual decision making, policy, and trials research are discussed.

COVID-19 related negative emotions and emotional suppression are associated with greater risk perceptions among emergency nurses: A cross-sectional study

Background

As the COVID-19 pandemic began, frontline nurses experienced many emotions as they faced risks relevant to both patients (e.g., making errors resulting in patient harm) and themselves (e.g., becoming infected with COVID-19). Although emotions are often neglected in the patient safety literature, research in affective science suggests that emotions may significantly impact nurses' perceptions of risk, which can have downstream consequences. Further, the use of chronic emotion regulation strategies that are known to differ in adaptability and effectiveness (i.e., emotional suppression, reappraisal) can impact risk perceptions.

Objective

To investigate the relationship between nurses' emotional experiences in response to the pandemic and their estimates of how likely they would be to experience adverse outcomes related to both patients and themselves within the next six months. Additionally, we investigated the extent to which the use of suppression and reappraisal processes to manage emotions are associated with these risk perceptions.

Design

Cross-sectional survey.

Setting

Online survey distributed via email to emergency nurses at eight hospitals in the northeastern United States during fall 2020.

Participants

132 emergency nurses (M _age = 37.05; 81.1% Female; 89.4% White).

Methods

Nurses reported the extent to which they experienced a variety of positive (e.g., hope, optimism) and negative (e.g., fear, sadness) emotions in response to the COVID-19 pandemic, and reported their perceptions of risk to both patients and themselves. Nurses also completed the Emotion Regulation Questionnaire, a measure of chronic tendencies to engage in emotional suppression and reappraisal. Immediately prior to providing data for this study, nurses completed an unrelated decision-making study.

Results

Nurses' negative emotions in response to COVID-19 were associated with greater perceptions of both patient safety risks (b = 0.31, p < .001) and personal risks (b = 0.34, p < .001). The relationships between positive emotions and risk perceptions were not statistically significant (all p values > 0.66). Greater chronic tendencies to suppress emotions uniquely predicted greater perceptions of patient safety risks (b = 2.91, p = .036) and personal risks (b = 2.87, p = .040) among nurses; however, no statistically significant relationships with reappraisal emerged (all p values > 0.16).

Conclusions

Understanding factors that influence perceptions of risk are important, given that these perceptions can motivate behaviours that may adversely impact patient safety. Such an understanding is essential to inform the development of interventions to mitigate threats to patient safety that emerge from nurses' negative emotional experiences and their use of different emotion regulation strategies.

Tweetable abstract

Covid-related negative emotions and emotional suppression are associated with greater patient and personal risk perceptions among emergency nurses @lindamisbell @Nathan_Huff_1.

Generalised decision curve analysis for explicit comparison of treatment effects

RATIONALE

Decision curve analysis (DCA) helps integrate prediction models with treatment assessments to guide personalised therapeutic choices among multiple treatment options. However, the current versions of DCA do not explicitly model treatment effects in the analysis but implicitly or holistically assess therapeutic benefits and harms. In addition, the existing DCA cannot allow the comparison of multiple treatments using a standard metric.

AIMS AND OBJECTIVES

To develop a generalised version of DCA (gDCA) by decomposing holistically assessed net benefits and harms into patient preferences versus empirical evidence (as obtained in the trials, meta-analyses of clinical studies, etc.) to allow individualised comparison of single or multiple treatments using a common metric.

METHODS

We reformulated DCA by (1) decomposing holistic, implicit utilities into specific utilities related to treatment effects and patient's relative values (RV) about disease outcomes versus treatment harms, (2) explicitly modelling each treatment effect at the level of probabilities and/or utilities (outcomes) in a decision tree, and (3) avoiding scaling effects employed in the original DCA to enable comparison of treatment effects against the common metrics. We used data from a published network meta-analysis of randomised trials to inform the use of statin treatment according to Framingham Risk Model.

RESULTS

We illustrate the analysis by modelling the effects of three statins in the primary prevention of cardiovascular disease. We performed simultaneous comparisons against standard metrics (RV) for all treatments. We examined for which RV values, a predictive model for guiding personalised treatment, outperformed the strategies of treating everyone or treating no one. We found that the magnitude of benefits (efficacy) seems more important than the simple ratio of efficacy/harms.

CONCLUSION

We describe gDCA for evaluating single or multiple treatments to help tailor therapy toward individual risk characteristics. gDCA further helps integrate the principles of evidence-based medicine with decision analysis.

Patients, doctors and risk attitudes

A lively topic of debate in decision theory over recent years concerns our understanding of the different risk attitudes exhibited by decision makers. There is ample evidence that risk-averse and risk-seeking behaviours are widespread, and a growing consensus that such behaviour is rationally permissible. In the context of clinical medicine, this matter is complicated by the fact that healthcare professionals must often make choices for the benefit of their patients, but the norms of rational choice are conventionally grounded in a decision maker's own desires, beliefs and actions. The presence of both doctor and patient raises the question of whose risk attitude matters for the choice at hand and what to do when these diverge. Must doctors make risky choices when treating risk-seeking patients? Ought they to be risk averse in general when choosing on behalf of others? In this paper, I will argue that healthcare professionals ought to adopt a deferential approach, whereby it is the risk attitude of the patient that matters in medical decision making. I will show how familiar arguments for widely held anti-paternalistic views about medicine can be straightforwardly extended to include not only patients' evaluations of possible health states, but also their attitudes to risk. However, I will also show that this deferential view needs further refinement: patients' higher-order attitudes towards their risk attitudes must be considered in order to avoid some counterexamples and to accommodate different views about what sort of attitudes risk attitudes actually are.

Decomposing clinical practice guidelines panels' deliberation into decision theoretical constructs

RATIONALE, AIMS AND OBJECTIVES: The development of clinical practice guidelines (CPG) suffers from the lack of an explicit and transparent framework for synthesising the key elements necessary to formulate practice recommendations. We matched deliberations of the American Society of Haematology (ASH) CPG panel for the management of pulmonary embolism (PE) with the corresponding decision-theoretical constructs to assess agreement of the panel recommendations with explicit decision modelling.

METHODS

Five constructs were identified of which three were used to reformulate the panel's recommendations: (1) standard, expected utility threshold (EUT) decision model; (2) acceptable regret threshold model (ARg) to determine the frequency of tolerable false negative (FN) or false positive (FP) recommendations, and (3) fast-and-frugal tree (FFT) decision trees to formulate the entire strategy for management of PE. We compared four management strategies: withhold testing versus d-dimer → computerized pulmonary angiography (CTPA) ('ASH-Low') versus CTPA→ d-dimer ('ASH-High') versus treat without testing.

RESULTS

Different models generated different recommendations. For example, according to EUT, testing should be withheld for prior probability PE < 0.13%, a clinically untenable threshold which is up to 15 times (2/0.13) below the ASH guidelines threshold of ruling out PE (at post probability of PE ≤ 2%). Three models only agreed that the 'ASH low' strategy should be used for the range of pretest probabilities of PE between 0.13% and 13.27% and that the 'ASH high' management should be employed in a narrow range of the prior PE probabilities between 90.85% and 93.07%. For all other prior probabilities of PE, choosing one model did not ensure coherence with other models.

CONCLUSIONS

CPG panels rely on various decision-theoretical strategies to develop its recommendations. Decomposing CPG panels' deliberation can provide insights if the panels' deliberation retains a necessary coherence in developing guidelines. CPG recommendations often do not agree with the EUT decision analysis, widely used in medical decision-making modelling.

Regret affects the choice between neoadjuvant therapy and upfront surgery for potentially resectable pancreatic cancer

BACKGROUND

When treating potentially resectable pancreatic adenocarcinoma, therapeutic decisions are left to the sensibility of treating clinicians who, faced with a decision that post hoc can be proven wrong, may feel a sense of regret that they want to avoid. A regret-based decision model was applied to evaluate attitudes toward neoadjuvant therapy versus upfront surgery for potentially resectable pancreatic adenocarcinoma.

METHODS

Three clinical scenarios describing high-, intermediate-, and low-risk disease-specific mortality after upfront surgery were presented to 60 respondents (20 oncologists, 20 gastroenterologists, and 20 surgeons). Respondents were asked to report their regret of omission and commission regarding neoadjuvant chemotherapy on a scale between 0 (no regret) and 100 (maximum regret). The threshold model and a multilevel mixed regression were applied to analyze respondents' attitudes toward neoadjuvant therapy.

RESULTS

The lowest regret of omission was elicited in the low-risk scenario, and the highest regret in the high-risk scenario (P < .001). The regret of the commission was diametrically opposite to the regret of omission (P ≤ .001). The disease-specific threshold mortality at which upfront surgery is favored over the neoadjuvant therapy progressively decreased from the low-risk to the high-risk scenarios (P ≤ .001). The nonsurgeons working in or with lower surgical volume centers (P = .010) and surgeons (P = .018) accepted higher disease-specific mortality after upfront surgery, which resulted in the lower likelihood of adopting neoadjuvant therapy.

CONCLUSION

Regret drives decision making in the management of pancreatic adenocarcinoma. Being a surgeon or a specialist working in surgical centers with lower patient volumes reduces the likelihood of recommending neoadjuvant therapy.

Evidence and Decision-Making

Today, every country struggles to provide adequate health care to its citizens. Globally, an average of $8.3 trillion or 10% of gross domestic product (GDP) is annually spent on health services. In 2019, the USA spent nearly 18% ($3.2 trillion) of its GDP on health care, projected to reach $6.2 trillion by 2028.

Which Threshold Model?

As outlined in the Preface (and Chap. 1 and other chapters), this book espoused two fundamental views. The first view consists of the proposal that the threshold model represents a method to address the Sorites paradox, which is a consequence of a relationship between scientific evidence (that exists on a continuum of credibility) and decision-making (that is categorical, yes/no exercises).

Making Decisions When no Further Diagnostic Testing is Available (Expected Regret Theory Threshold Model)

In Chap. 2 , we illustrated the application of the expected utility theory (EUT) to rational decision-making when no further diagnostic testing is available. In this chapter, we apply regret theory to the decision problems discussed in Chap. 2 .

Adoption of Patient-Reported Outcomes by Health Systems and Physician Practices in the USA

BACKGROUND

Patient-reported outcome measures (PROs) can help clinicians adjust treatments and deliver patient-centered care, but organizational adoption of PROs remains low.

OBJECTIVE

This study examines the extent of PRO adoption among health systems and physician practices nationally and examines the organizational capabilities associated with more extensive PRO adoption.

DESIGN

Two nationally representative surveys were analyzed in parallel to assess health system and physician practice capabilities associated with adoption of PROs of disability, pain, and depression.

PARTICIPANTS

A total of 323 US health system and 2,190 physician practice respondents METHODS: Multivariable regression models separately estimated the association of health system and physician practice capabilities associated with system-level and practice-level adoption of PROs.

MAIN MEASURES

Health system and physician practice adoption of PROs for depression, pain, and disability.

KEY RESULTS

Pain (50.6%) and depression (43.8%) PROs were more commonly adopted by all hospitals and medical groups within health systems compared to disability PROs (26.5%). In adjusted analyses, systems with more advanced health IT functions were more likely to use disability (p<0.05) and depression (p<0.01) PROs than systems with less advanced health IT. Practice-level advanced health IT was positively associated with use of depression PRO (p<0.05), but not disability or pain PRO use. Practices with more chronic care management processes, broader medical and social risk screening, and more processes to support patient responsiveness were more likely to adopt each of the three PROs. Compared to independent physician practices, system-owned practices and community health centers were less likely to adopt PROs.

CONCLUSIONS

Chronic care management programs, routine screening, and patient-centered care initiatives can enable PRO adoption at the practice level. Developing these practice-level capabilities may improve PRO adoption more than solely expanding health IT functions.

Rehabilitation Evidence-Based Decision-Making: The READ Model

Evidence-based practice is the foundation of rehabilitation for maximizing client outcomes. However, an unacceptably high number of ineffective or outdated interventions are still implemented, leading to sub-optimal outcomes for clients. This paper proposes the Rehabilitation Evidence bAsed Decision-Making (READ) Model, a decision-making algorithm for evidence-based decision-making in rehabilitation settings. The READ Model outlines a step-by-step layered process for healthcare professionals to collaboratively set goals, and to select appropriate interventions. The READ Model acknowledges the important multi-layered contributions of client's preferences and values, family supports available, and external environmental factors such as funding, availability of services and access. Healthcare professionals can apply the READ Model to choose interventions that are evidence-based, with an appropriate mode, dose, and with regular review, in order to achieve client's goals. Two case studies are used to demonstrate application of the READ Model: cerebral palsy and autism spectrum disorder. The READ Model applies the four central principles of evidence-based practice and can be applied across multiple rehabilitation settings.

A qualitative approach to identify clinical uncertainty in practicing physicians and clinical residents

BACKGROUND

Clinical decision-making is not only stressful to physicians, but also to patients and even their companions. Thus, managing uncertainty in clinical decision-making is essential which requires knowing its origins. Therefore, this study aimed to understand determinants of uncertainty in clinical decision-making from the perspective of clinical physicians.

MATERIALS AND METHODS

This is a qualitative study which is done during October to November 2020. An in-depth interview is performed with 24 specialists of clinical groups including obstetrics, surgery, internal medicine, and pediatrics, working in teaching hospitals affiliated to Iran University of Medical Sciences. All the interviews were recorded, transcribed and analyzed according to the steps suggested by Graneheim and Lundman. The interviews were analyzed through comparative method. Then, the interviewer created initial codes, categories, and key concepts and sent them to fourteen physicians for member check.

RESULTS

According to the participants' view, determinants of uncertainty in clinical decision-making consisted of three themes: individual determinants, dynamics of medical sciences, and diagnostic and instrumental constraint. Individual determinants can be related to the physician or patient. The dynamics of medical sciences could be explained in two categories: variation of medical science and complexity. Diagnostic and instrumental constraint category could be also explained in subcategories such as lack of efficient diagnostic tests and unknown etiology.

CONCLUSION

To curb uncertainty, the more accessible way is considering interventional programs with a focus on individual determinants related to physicians, such as strengthening doctor-patient relationships, and considering related mandatory retraining courses to reduce insufficient knowledge of physicians.

Evidence-to-decision frameworks: a review and analysis to inform decision-making for environmental health interventions

BACKGROUND

Evidence-to-decision (EtD) frameworks provide a structured and transparent approach for groups of experts to use when formulating recommendations or making decisions. While extensively used for clinical and public health recommendations, EtD frameworks are not in widespread use in environmental health. This review sought to identify, compare and contrast key EtD frameworks for decisions on interventions used in clinical medicine, public health or environmental health. This information can be used to develop an EtD framework suitable for formulating recommendations for interventions in environmental health.

METHODS

We identified a convenience sample of EtD frameworks used by a range of organizations. We searched Medline for systematic reviews of frameworks. We summarized the decision criteria in the selected frameworks and reviews in a qualitative manner.

FINDINGS

Fourteen organizations provided 18 EtD frameworks; most frameworks focused on clinical medicine or public health interventions; four focused on environmental health and three on economic considerations. Harms of interventions were examined in all frameworks and benefits in all but one. Other criteria included certainty of the body of evidence (15 frameworks), resource considerations (15), feasibility (13), equity (12), values (11), acceptability (11), and human rights (2). There was variation in how specific criteria were defined. The five identified systematic reviews reported a similar spectrum of EtD criteria.

INTERPRETATION

The EtD frameworks examined encompassed similar criteria, with tailoring to specific audience needs. Existing frameworks are a useful starting point for development of one tailored to decision-making in environmental health.

FUNDER

JPB Foundation.

Ethics of uncertainty

Uncertainty is inherent in clinical medicine. However, just because absolute certainty is unachievable does not mean that rational and optimal decisions cannot be made. It is argued that we need to distinguish legitimate from illegitimate scientific uncertainties that are generated by manufacturing doubts aiming to create mis- and disinformation. The attempt to create doubts implies that actions under uncertainties are impossible. Such a belief ultimately harms public, which requires reasoned actions within a context of genuine scientific and medical uncertainties. The latter indicates that rational decisions, even in the absence of guaranteed absolute certainty, are not only possible but, on average, beneficial both for society and individuals.

When are randomized trials unnecessary? A signal detection theory approach to approving new treatments based on non-randomized studies

RATIONALE, AIMS AND OBJECTIVES

New therapies are increasingly approved by regulatory agencies such as the Food and Drug Administration (FDA) and the European Medicines Agency (EMA) based on testing in non-randomized clinical trials. These treatments have typically displayed "dramatic effects" (ie, effects that are considered large enough to obviate the combined effects of biases and random errors that may affect the study results). The agencies, however, have not identified how large these effects should be to avoid the need for further testing in randomized controlled trials (RCTs). We investigated the effect size that would circumvent the need for further RCTs testing by the regulatory agencies. We hypothesized that the approval of therapeutic interventions by regulators is based on heuristic decision making whose accuracy can be best characterized by the application of signal detection theory (SDT).

METHODS

We merged the EMA and FDA database of approvals based on non-RCT comparisons. We excluded duplicate entries between the two databases. We included a total of 134 approvals of drugs and devices based on non-RCTs. We integrated Weber-Fechner law of psychophysics and recognition heuristics within SDT to provide descriptive explanations of the decisions made by the FDA and EMA to approve new treatments based on non-randomized studies without requiring further testing in RCTs.

RESULTS

Our findings suggest that when the difference between novel treatments and the historical control is at least one logarithm (base 10) of magnitude, the veracity of testing in non-RCTs seems to be established.

CONCLUSION

Drug developers and practitioners alike can use the change in one logarithm of effect size as a benchmark to decide if further testing in RCTs should be pursued, or as a guide to interpreting the results reported in non-randomized studies. However, further research would be useful to better characterize the threshold of effect size above which testing in RCTs is not needed.

Certainty of evidence and intervention's benefits and harms are key determinants of guidelines' recommendations

OBJECTIVE

Many factors are postulated to affect guidelines developments. We set out to identify the key determinants.

STUDY DESIGN AND SETTING

a) Web-based survey of 12 panels of 153 "voting" members who issued 2941 recommendations; b) qualitative analysis of 13 panels of 311 attendees (panel members, systematic review teams and observers).

RESULTS

Compared with "no recommendations", when intervention's benefit outweigh harms (BH-balance), probability of issuing strong recommendations in favor of intervention was 0.22 (95%CI: 0.08 to 0.36) when certainty of evidence (CoE) was very low; 0.5 (95%CI:0.36 to 0.63) when low; 0.74 (95%CI 0.61 to 0.87) when moderate and 0.85 (95%CI:0.71 to 1.00) when high. No other postulated factor significantly affected recommendations. The findings are consistent with a J- curve model when recommendations are issued in favor but not against an intervention. Panelists often changed their judgments as a result of the meeting discussion (67% for CoE to 92% for balance between benefits and harms). The panels spent over 50% of their time debating CoE; the chairs and co-chairs dominated discussion.

CONCLUSIONS

CoE and BH-balance are key determinants of recommendations in favor of an intervention. Chairs and co-chairs dominate discussion. Panelists often change their judgments as a result of panel deliberation.

Clinical pathways and patient-related outcomes in hospital-based settings: a systematic review and meta-analysis of randomized controlled trials

Clinical pathways represent a multi-disciplinary approach to translate clinical practice guidelines into practical interventions. The literature from 2010 onward regarding the efficacy of adopting a clinical pathway on patient-related outcomes within the in-hospital setting has not been synthesized yet. For this reason, this systematic review and meta-analysis of randomized controlled trials aimed to critically synthesize the literature from 2010 onward about the efficacy of clinical pathways, compared with standard of care, on patient-related outcomes in different populations and to determine the effects of clinical pathways on patient outcomes. We searched PubMed, Scopus, CINAHL, and reference lists of the included studies. Two independent reviewers screened the 360 identified articles and selected fifteen eligible articles, which were evaluated for content and risk of bias. Eleven studies were finally included. Given the commonalities of the measured outcomes, a meta-analysis including eight studies was performed to evaluate the effect size of the associations between clinical pathways and quality of life (OR=1.472 [0.483–4.486]; p=0.496), and two meta-analyses, including four studies, were performed to evaluate the effect sizes of the associations between clinical pathways with satisfaction (OR=2.226 [0.868–5.708]; p=0.096) and length of stay (OR=0,585 [0.349–0.982]; p=0.042). Reduced length of stay appeared to be associated with clinical pathways, while it remains unclear whether adopting clinical pathways could improve levels of quality of life and satisfaction. More primary research is required to determine in specific populations the efficacy of clinical pathways on patient-related outcomes. (www.actabiomedica.it)

What is optimal in optimal inference?

Inferring hidden structure from noisy observations is a problem addressed by Bayesian statistical learning, which aims to identify optimal models of the process that generated the observations given assumptions that constrain the space of potential solutions. Animals and machines face similar "model-selection" problems to infer latent properties and predict future states of the world. Here we review recent attempts to explain how intelligent agents address these challenges and how their solutions relate to Bayesian principles. We focus on how constraints on available information and resources affect inference and propose a general framework that uses benefit(accuracy) and accuracy(cost) curves to assess optimality under these constraints.

Quality Assessment and Risk of Bias of Systematic Reviews of Prophylactic Mesh for Parastomal Hernia Prevention Using AMSTAR and ROBIS Tools

BACKGROUND

Systematic reviews play a crucial role in clinical decision making and resource allocation and are expected to be unbiased and consistent. The aim of this study is a review of systematic reviews on the use of prophylactic mesh to prevent parastomal hernia (PH) formation using ROBIS and AMSTAR tools to assess the risk of bias and methodological quality.

METHODS

We included systematic reviews with or without meta-analysis of which the objective was to assess the use of a prophylactic mesh to prevent PH. A systematic search of the literature in five databases from inception until December 2017 was conducted. For each systematic review, methodologic quality and risk of bias were assessed using the AMSTAR and ROBIS tools, respectively. We estimated the inter-rater reliability for individual domains and for the overall methodological quality and risk of bias using Fleiss' k.

RESULTS

We identified 14 systematic reviews that met the inclusion criteria. Using the AMSTAR scale with a cutoff value, six reviews showed high methodologic quality and eight were of low quality. Using the ROBIS tool, the overall risk of bias was low in 50% of the reviews analyzed. In the remaining studies, the risk of bias was unclear.

CONCLUSIONS

The global evidence in favor of the use of a prophylactic mesh for preventing PH is not uniform regarding quality and risk of bias. Surgeons cannot be equally confident in the results of all systematic reviews published on this topic.

Cohort study evaluating management of burns in the community in clinical practice in the UK: costs and outcomes

OBJECTIVE

To evaluate health outcomes, resource use and corresponding costs attributable to managing burns in clinical practice, from initial presentation, among a cohort of adults in the UK.

DESIGN

Retrospective cohort analysis of the records of a randomly selected cohort of 260 patients from The Health Improvement Network (THIN) database who had 294 evaluable burns.

SETTING

Primary and secondary care sectors in the UK.

PRIMARY AND SECONDARY OUTCOME MEASURES

Patients' characteristics, wound-related health outcomes, healthcare resource use and total National Health Service (NHS) cost of patient management.

RESULTS

Diagnosis was incomplete in 63% of patients' records as the location, depth and size of the burns were missing. Overall, 70% of all the burns healed within 24 months and the time to healing was a mean of 7.8 months per burn. Sixty-six per cent of burns were initially managed in the community and the other 34% were managed at accident and emergency departments. Patients' wounds were subsequently managed predominantly by practice nurses and hospital outpatient clinics. Forty-five per cent of burns had no documented dressings in the patients' records. The mean NHS cost of wound care in clinical practice over 24 months from initial presentation was an estimated £16 924 per burn, ranging from £12 002 to £40 577 for a healed and unhealed wound, respectively.

CONCLUSIONS

Due to incomplete documentation in the patients' records, it is difficult to say whether the time to healing was excessive or what other confounding factors may have contributed to the delayed healing. This study indicates the need for education of general practice clinicians on the management and care of burn wounds. Furthermore, it is beholden on the burns community to determine how the poor healing rates can be improved. Strategies are required to improve documentation in patients' records, integration of care between different providers, wound healing rates and reducing infection.

The ecological rationality of explanatory reasoning

There is growing evidence that explanatory considerations influence how people change their degrees of belief in light of new information. Recent studies indicate that this influence is systematic and may result from people's following a probabilistic update rule. While formally very similar to Bayes' rule, the rule or rules people appear to follow are different from, and inconsistent with, that better-known update rule. This raises the question of the normative status of those updating procedures. Is the role explanation plays in people's updating their degrees of belief a bias? Or are people right to update on the basis of explanatory considerations, in that this offers benefits that could not be had otherwise? Various philosophers have argued that any reasoning at deviance with Bayesian principles is to be rejected, and so explanatory reasoning, insofar as it deviates from Bayes' rule, can only be fallacious. We challenge this claim by showing how the kind of explanation-based update rules to which people seem to adhere make it easier to strike the best balance between being fast learners and being accurate learners. Borrowing from the literature on ecological rationality, we argue that what counts as the best balance is intrinsically context-sensitive, and that a main advantage of explanatory update rules is that, unlike Bayes' rule, they have an adjustable parameter which can be fine-tuned per context. The main methodology to be used is agent-based optimization, which also allows us to take an evolutionary perspective on explanatory reasoning.

What do emergency department physicians and nurses feel? A qualitative study of emotions, triggers, regulation strategies, and effects on patient care

BACKGROUND

Despite calls to study how healthcare providers' emotions may impact patient safety, little research has addressed this topic. The current study aimed to develop a comprehensive understanding of emergency department (ED) providers' emotional experiences, including what triggers their emotions, the perceived effects of emotions on clinical decision making and patient care, and strategies providers use to manage their emotions to reduce patient safety risks.

METHODS

Employing grounded theory, we conducted 86 semi-structured qualitative interviews with experienced ED providers (45 physicians and 41 nurses) from four academic medical centres and four community hospitals in the Northeastern USA. Constant comparative analysis was used to develop a grounded model of provider emotions and patient safety in the ED.

RESULTS

ED providers reported experiencing a wide range of emotions in response to patient, hospital, and system-level factors. Patients triggered both positive and negative emotions; hospital and system-level factors largely triggered negative emotions. Providers expressed awareness of possible adverse effects of negative emotions on clinical decision making, highlighting concerns about patient safety. Providers described strategies they employ to regulate their emotions, including emotional suppression, distraction, and cognitive reappraisal. Many providers believed that these strategies effectively guarded against the risk of emotions negatively influencing their clinical decision making.

CONCLUSION

The role of emotions in patient safety is in its early stages and many opportunities exist for researchers, educators, and clinicians to further address this important issue. Our findings highlight the need for future work to (1) determine whether providers' emotion regulation strategies are effective at mitigating patient safety risk, (2) incorporate emotional intelligence training into healthcare education, and (3) shift the cultural norms in medicine to support meaningful discourse around emotions.

Gender role orientation, thinking style preference and facets of adult paranormality: A mediation analysis

This study examines the extent to which masculine and feminine gender role orientations predict self-reported anomalous experiences, belief, ability and fear once relevant correlates including biological sex are controlled for. The extent to which rational versus intuitive thinking style preference mediates these relationships is also examined. Path analysis (n = 332) found heightened femininity directly predicts stronger intuitive preference plus more anomalous experiences, belief and fear with, additionally, intuitive preference mediating several gender role-paranormality relationships. By comparison, heightened masculinity directly predicts both thinking styles plus lower anomalous fear. The latter relationship is also shaped by the nature of mediators with (a) more anomalous experiences and belief associated with more anomalous fear and (b) either heightened rationality else more anomalous ability linked to, conversely, less anomalous fear. The extent to which findings support a gender (or social) role account of adult paranormality, together with methodological limitations and ideas for future research, is discussed.

Economic implications of outpatient cardiac catheterisation in infants with single ventricle congenital heart disease

BACKGROUND

Resource utilisation for infants with single ventricle CHD remains high without well-studied ways to decrease economic burden. Same-day discharge following cardiac catheterisation has been shown to be safe and effective in children with CHD, but those with single ventricle physiology are commonly excluded. The purpose of this study was to investigate the economic implications of planned same-day discharge following cardiac catheterisation versus universal overnight hospital admission in infants with single ventricle CHD.

METHODS AND RESULTS

A probabilistic decision-tree analysis with sensitivity analyses was performed. All included patients were categorised into four possible outcomes; discharge, readmission following discharge (within 48 hours), observation and prolonged hospitalisation. Baseline probabilities of each node of the tree were then combined with the cost data to evaluate the comparative dominance of one decision (immediately discharge) versus the other decision (routinely admit). Patients discharged on the same day as the procedure accrued the lowest attributed hospital cost ($5469), while patients readmitted to the hospital had the highest attributed cost ($11,851). Currently, no other studies have assessed the cost of hospitalisation following cardiac catheterisation in this population. Thus, we allowed for a wide range of cost variation, but same-day discharge dominated the decision outcome with a lower economic burden.

CONCLUSION

Same-day discharge following routine cardiac catheterisation in patients with single ventricle physiology is less costly compared to universal overnight admission. This demonstrates an important cost-limiting step in a complex population of patients who have high resource utilisation.

A unifying framework for improving health care

The quality health care around world is suboptimal. To improve the quality of contemporary health care delivery, advocates have proposed a number of scientific and technical initiatives. All these initiatives, however, have arisen and continue to operate in siloes, resulting in confusion and incommensurability among those concerned with health care improvement. Participants in the quality improvement (QI) space typically stress their own, often narrow, perspective, failing to place QI in context or to acknowledge other approaches. In order to improve delivery of health care, the following is required: Provide a unifying framework for improving health care. We argue this is best done under a Health System Science (HSS) framework but with full understanding that the fundamental principles of HSS are rooted in evidence-based medicine (EBM) and decision sciences. Understand that QI initiatives are fundamentally local activities. Hence, incentivizing bottom-up, local QI initiatives would improve health care delivery to a far greater extent than the current top-down initiatives undertaken in a response to various regulatory mandates. Akin to the "Choosing Wisely" initiative, which challenged professional societies, each institution should identify (a) the extent to which its practices are evidence-based and (b) the top 5 health care practices or interventions that, at a given institution, represent overuse, underuse, or misuse/error or undermine clinicians' efforts to deliver kind and empathic care. Providing a framework that can unify the current patchwork of the initiatives would help create a common basis to help align all the existing QI efforts. In addition, thinking small (at local level) may lead to health care quality improvements that national initiatives (thinking big), focused on regulation, competition, or legal requirements, have failed to achieve.

Failure to place evidence at the centre of quality improvement remains a major barrier for advances in quality improvement

Mondoux and Shojania (M&S) issued a critique of our call to unify all disciplines of relevance for quality improvement (QI). They do not challenge the need for alignment of different fields that have played roles in the QI space. They selected to focus their critique on our views that ultimately the discipline of QI should be based on the principles of evidence-based medicine (EBM) and decision sciences. In our response, we reaffirm our calls to help achieve needed alignment and integration of all disciplines of importance to QI through "a unifying framework for improving health care" with EBM and decision sciences at helm. Challenging the importance of placing QI on solid empirical basis is misguided: As QI is all about measuring and consequently improving clinical care, acting on reliable evidence must remain its "cornerstone". Apparent differences in our views appears to be due to our focus on what care should be delivered, while M&S concentrate on how that care should be delivered. The former is the domain of a narrowly defined EBM, while the latter is the realm of improvement/implementation science-which, we argue, should also be evidence-based. QI initiatives are fundamentally local activities, and regulators would be most helpful if they require each institution to provide an annual plan of its top QI activities not included in the existing mandated list of performance measures. Finally, we addressed a number of specific QI initiatives highlighted by M&S-use of opioids, handwashing, venous-thromboembolism prophylaxis, hip replacement, and perioperative beta-blockers-to show that they would have been carried differently if they were based on the principles of EBM. Thus, the failure to place evidence at the centre remains a major barrier for advances in QI.

Primary care physicians' decision-making processes in the context of multimorbidity: protocol of a systematic review and thematic synthesis of qualitative research

INTRODUCTION

Good patient outcomes correlate with the physicians' capacity for good clinical judgement. Multimorbidity is common and it increases uncertainty and complexity in the clinical encounter. However, healthcare systems and medical education are centred on individual diseases. In consequence, recognition of the patient as the centre of the decision-making process becomes even more difficult. Research in clinical reasoning and medical decision in a real-world context is needed. The aim of the present review is to identify and synthesise available qualitative evidence on primary care physicians' perspectives, views or experiences on decision-making with patients with multimorbidity.

METHODS AND ANALYSIS

This will be a systematic review of qualitative research where PubMed, CINAHL, PsycINFO, Embase and Web of Science will be searched, supplemented with manual searches of reference lists of included studies. Qualitative studies published in Portuguese, Spanish and English language will be included, with no date limit. Studies will be eligible when they evaluate family physicians' perspectives, opinions or perceptions on decision-making for patients with multimorbidity in primary care. The methodological quality of studies selected for retrieval will be assessed by two independent reviewers before inclusion in the review using the Critical Appraisal Skills Programme (CASP) tool. Thematic synthesis will be used to identify key categories and themes from the qualitative data. The Confidence in the Evidence from Reviews of Qualitative research approach will be used to assess how much confidence to place in findings from the qualitative evidence synthesis.

ETHICS AND DISSEMINATION

This review will use published data. No ethical issues are foreseen. The findings will be disseminated to the medical community via journal publication and conference presentation(s).

PROSPERO REGISTRATION NUMBER

ID 91978.

The threshold model revisited

BACKGROUND

The threshold model represents one of the most significant advances in the field of medical decision-making, yet it often does not apply to the most common class of clinical problems, which include health outcomes as a part of definition of disease. In addition, the original threshold model did not take a decision-maker's values and preferences explicitly into account.

METHODS

We reformulated the threshold model by (1) applying it to those clinical scenarios, which define disease according to outcomes that treatment is designed to affect, (2) taking into account a decision-maker's values.

RESULTS

We showed that when outcomes (eg, morbidity) are integral part of definition of disease, the classic threshold model does not apply (as this leads to double counting of outcomes in the probabilities and utilities branches of the model). To avoid double counting, the model can be appropriately analysed by assuming diagnosis is certain (P = 1). This results in deriving a different threshold-the threshold for outcome of disease (M_t ) instead of threshold for probability of disease (P_t ) above which benefits of treatment outweigh its harms. We found that M_t  ≤ P_t , which may explain differences between normative models and actual behaviour in practice. When a decision-maker values outcomes related to benefit and harms differently, the new threshold model generates decision thresholds that could be descriptively more accurate.

CONCLUSIONS

Calculation of the threshold depends on careful disease versus utility definitions and a decision-maker's values and preferences.

Treating real people: Science and humanity

Something important is happening in applied, interdisciplinary research, particularly in the field of applied health research. The vast array of papers in this edition are evidence of a broad change in thinking across an impressive range of practice and academic areas. The problems of complexity, the rise of chronic conditions, overdiagnosis, co-morbidity, and multi-morbidity are serious and challenging, but we are rising to that challenge. Key conceptions regarding science, evidence, disease, clinical judgement, and health and social care are being revised and their relationships reconsidered: Boundaries are indeed being redrawn; reasoning is being made "fit for practice." Ideas like "person-centred care" are no longer phrases with potential to be helpful in some yet-to-be-clarified way: Theorists and practitioners are working in collaboration to give them substantive import and application.

Transforming clinical practice guidelines and clinical pathways into fast-and-frugal decision trees to improve clinical care strategies

BACKGROUND

Contemporary delivery of health care is inappropriate in many ways, largely due to suboptimal Q5 decision-making. A typical approach to improve practitioners' decision-making is to develop evidence-based clinical practice guidelines (CPG) by guidelines panels, who are instructed to use their judgments to derive practice recommendations. However, mechanisms for the formulation of guideline judgments remains a "black-box" operation-a process with defined inputs and outputs but without sufficient knowledge of its internal workings.

METHODS

Increased explicitness and transparency in the process can be achieved by implementing CPG as clinical pathways (CPs) (also known as clinical algorithms or flow-charts). However, clinical recommendations thus derived are typically ad hoc and developed by experts in a theory-free environment. As any recommendation can be right (true positive or negative), or wrong (false positive or negative), the lack of theoretical structure precludes the quantitative assessment of the management strategies recommended by CPGs/CPs.

RESULTS

To realize the full potential of CPGs/CPs, they need to be placed on more solid theoretical grounds. We believe this potential can be best realized by converting CPGs/CPs within the heuristic theory of decision-making, often implemented as fast-and-frugal (FFT) decision trees. This is possible because FFT heuristic strategy of decision-making can be linked to signal detection theory, evidence accumulation theory, and a threshold model of decision-making, which, in turn, allows quantitative analysis of the accuracy of clinical management strategies.

CONCLUSIONS

Fast-and-frugal provides a simple and transparent, yet solid and robust, methodological framework connecting decision science to clinical care, a sorely needed missing link between CPGs/CPs and patient outcomes. We therefore advocate that all guidelines panels express their recommendations as CPs, which in turn should be converted into FFTs to guide clinical care.

Evidence to Decision framework provides a structured "roadmap" for making GRADE guidelines recommendations

OBJECTIVES

It is unclear how guidelines panelists discuss and consider factors (criteria) that are formally and not formally included in the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. To describe the use of decision criteria, we explored how panelists adhered to GRADE criteria and sought to identify any emerging non-GRADE criteria when the panelists used the Evidence to Decision (EtD) framework as part of GRADE application.

STUDY DESIGN AND SETTING

We used conventional and summative qualitative analyses to identify themes emerging from face-to-face, panel meeting discussions. Forty-eight members from 12 countries participated in the development of five guidelines for the management of venous thromboembolism by the American Society of Hematology.

RESULTS

Ten themes corresponded to the GRADE approach and represented all panel discussions. Over half (53%) of the total panel discussions concerned the use of research evidence. When evidence was considered sufficient and clear, the decision-making process proved rapid.

CONCLUSION

The GRADE EtD framework provides structure to guidelines panel meetings, and ensures that the panelists consider all established formal GRADE criteria as they decide on the recommendation text, strength, and direction (for or against an intervention). This is the first study assessing the use of GRADE's EtD framework during real-time guidelines development using panel discussions. Given the widespread use of GRADE, this study provides important information for practice recommendations generated when guidelines panels explicitly follow, in a transparent and systematic manner, the structured GRADE EtD framework. By recognizing the extent to which panels discuss and consider GRADE and other (non-GRADE) criteria for producing guideline recommendations, we are one step closer to understanding the decision-making process in panels that use a structured framework such as the GRADE EtD framework.

Adaptive expertise in medical decision making

AIM

Recently, a growing awareness has developed of the extraordinary complexity of factors that influence the clinical reasoning underpinning the diagnostic process. The aim of the present report is to delineate these factors and suggest strategies for dealing more effectively with this complexity.

METHOD

Six major clusters of factors are described here: (A) individual characteristics of the decision maker, (B) individual intellectual and cognitive styles, (C) ambient and homeostatic factors, (D) factors in the work environment including team factors, (E) characteristics of the medical condition, and (F) factors associated with the patient. Additional factors, such as health care systems, culture, politics, and others are also important.

RESULTS

A review of the literature suggests that most clinicians trained under existing methods achieve a level of expertise presently referred to as "routine" or "classic." The results of studies of diagnostic failure, however, suggest that this level of expertise has proved insufficient. A growing literature suggests that more effective clinical decision might be achieved through adaptive reasoning, leading to enhanced levels of expertise and mastery.

CONCLUSIONS

It is proposed here that adaptive expertise may be achieved through emphasizing additional features of the reasoning process: being aware of the inhibitors and facilitators of rationality; pursuing the standards of critical thinking; developing a comprehensive awareness of cognitive and affective biases and how to mitigate them; developing a similar depth and understanding of logic and its fallacies; engaging metacognitive processes such as reflection and mindfulness; and through approaches embracing creativity, lateral thinking, and innovation.

Heuristic value-based framework for lung cancer decision-making

Heuristics and the application of fast-and-frugal trees may play a role in establishing a clinical decision-making framework for value-based oncology. We determined whether clinical decision-making in oncology can be structured heuristically based on the timeline of the patient's treatment, clinical intuition, and evidence-based medicine. A group of 20 patients with advanced non-small cell lung cancer (NSCLC) were enrolled into the study for extensive treatment analysis and sequential decision-making. The extensive clinical and genomic data allowed us to evaluate the methodology and efficacy of fast-and-frugal trees as a way to quantify clinical decision-making. The results of the small cohort will be used to further advance the heuristic framework as a way of evaluating a large number of patients within registries. Among the cohort whose data was analyzed, substitution and amplification mutations occurred most frequently. The top five most prevalent genomic alterations were TP53 (45%), ALK (40%), LRP1B (30%), CDKN2A (25%), and MYC (25%). These 20 cases were analyzed by this clinical decision-making process and separated into two distinctions: 10 straightforward cases that represented a clearer decision-making path and 10 complex cases that represented a more intricate treatment pathway. The myriad of information from each case and their distinct pathways was applied to create the foundation of a framework for lung cancer decision-making as an aid for oncologists. In late-stage lung cancer patients, the fast-and-frugal heuristics can be utilized as a strategy of quantifying proper decision-making with limited information.

Rational decision making in medicine: Implications for overuse and underuse

In spite of substantial spending and resource utilization, today's health care remains characterized by poor outcomes, largely due to overuse (overtesting/overtreatment) or underuse (undertesting/undertreatment) of health services. To a significant extent, this is a consequence of low-quality decision making that appears to violate various rationality criteria. Such suboptimal decision making is considered a leading cause of death and is responsible for more than 80% of health expenses. In this paper, we address the issue of overuse or underuse of health care interventions from the perspective of rational choice theory. We show that what is considered rational under one decision theory may not be considered rational under a different theory. We posit that the questions and concerns regarding both underuse and overuse have to be addressed within a specific theoretical framework. The applicable rationality criterion, and thus the "appropriateness" of health care delivery choices, depends on theory selection that is appropriate to specific clinical situations. We provide a number of illustrations showing how the choice of theoretical framework influences both our policy and individual decision making. We also highlight the practical implications of our analysis for the current efforts to measure the quality of care and link such measurements to the financing of health care services.

Many faces of rationality: Implications of the great rationality debate for clinical decision-making

Given that more than 30% of healthcare costs are wasted on inappropriate care, suboptimal care is increasingly connected to the quality of medical decisions. It has been argued that personal decisions are the leading cause of death, and 80% of healthcare expenditures result from physicians' decisions. Therefore, improving healthcare necessitates improving medical decisions, ie, making decisions (more) rational. Drawing on writings from The Great Rationality Debate from the fields of philosophy, economics, and psychology, we identify core ingredients of rationality commonly encountered across various theoretical models. Rationality is typically classified under umbrella of normative (addressing the question how people "should" or "ought to" make their decisions) and descriptive theories of decision-making (which portray how people actually make their decisions). Normative theories of rational thought of relevance to medicine include epistemic theories that direct practice of evidence-based medicine and expected utility theory, which provides the basis for widely used clinical decision analyses. Descriptive theories of rationality of direct relevance to medical decision-making include bounded rationality, argumentative theory of reasoning, adaptive rationality, dual processing model of rationality, regret-based rationality, pragmatic/substantive rationality, and meta-rationality. For the first time, we provide a review of wide range of theories and models of rationality. We showed that what is "rational" behaviour under one rationality theory may be irrational under the other theory. We also showed that context is of paramount importance to rationality and that no one model of rationality can possibly fit all contexts. We suggest that in context-poor situations, such as policy decision-making, normative theories based on expected utility informed by best research evidence may provide the optimal approach to medical decision-making, whereas in the context-rich circumstances other types of rationality, informed by human cognitive architecture and driven by intuition and emotions such as the aim to minimize regret, may provide better solution to the problem at hand. The choice of theory under which we operate is important as it determines both policy and our individual decision-making.