Is risk stratification ever the same as 'profiling'?

Challenges and Legal Gaps of Genetic Profiling in the Era of Big Data

Profiling of individuals based on inborn, acquired, and assigned characteristics is central for decision making in health care. In the era of omics and big smart data, it becomes urgent to differentiate between different data governance affordances for different profiling activities. Typically, diagnostic profiling is in the focus of researchers and physicians, and other types are regarded as undesired side-effects; for example, in the connection of health care insurance risk calculations. Profiling in a legal sense is addressed, for example, by the EU data protection law. It is defined in the General Data Protection Regulation as automated decision making. This term does not correspond fully with profiling in biomedical research and healthcare, and the impact on privacy has hardly ever been examined. But profiling is also an issue concerning the fundamental right of non-discrimination, whenever profiles are used in a way that has a discriminatory effect on individuals. Here, we will focus on genetic profiling, define related notions as legal and subject-matter definitions frequently differ, and discuss the ethical and legal challenges.

A decision-aid tool for ICU admission triage is associated with a reduction in potentially inappropriate intensive care unit admissions

PURPOSE

Intensive care unit (ICU) admission triage occurs frequently and often involves highly subjective decisions that may lead to potentially inappropriate ICU admissions. In this study, we evaluated the effect of implementing a decision-aid tool for ICU triage on ICU admission decisions.

METHODS

This was a prospective, before-after study. Urgent ICU referrals to ten ICUs in a tertiary hospital in Brazil were assessed before and after the implementation of the decision-aid tool. Our primary outcome was the proportion of potentially inappropriate ICU referrals (defined as priority 4B or 5 referrals, accordingly to the Society of Critical Care Medicine guidelines of 1999 and 2016, respectively) admitted to the ICU within 48 h. We conducted multivariate analyses to adjust for potential confounders and evaluated the interaction between phase and triage priority.

RESULTS

Of the 2201 patients analyzed, 1184 (53.8%) patients were admitted to the ICU. After adjustment for confounders, implementation of the decision-aid tool was associated with a reduction in potentially inappropriate ICU admissions using either the 1999 [adjOR (95% CI) = 0.36 (0.13-0.97)] or 2016 [adjOR (95%CI) = 0.35 (0.13-0.96)] definitions.

CONCLUSION

Implementation of a decision-aid tool for ICU triage was associated with a reduction in potentially inappropriate ICU admissions.

"I need to know what makes somebody tick …": Challenges and Strategies of Implementing Shared Decision-Making in Individualized Oncology

BACKGROUND

Shared decision-making (SDM) has been advocated as an ethical framework for decision-making in cancer care. According to SDM, patients make decisions in light of their values and based on the available evidence. However, SDM is difficult to implement in cancer care. A lack of applicability in practice is often reported. This empirical-ethical study explores factors potentially relevant to current difficulties in translating the concept of SDM into clinical practice.

METHODS

This study was conducted with nonparticipant observation of the decision-making process in patients with gastrointestinal cancers for whom the benefit of adjuvant chemotherapy was uncertain according to clinical guidelines. Triangulation of qualitative data analysis was conducted by means of semistructured interviews subsequent to the observation. Observation notes and interview transcripts were analyzed according to the principles of grounded theory.

RESULTS

Deviating from the concept of SDM, oncologists initiated a process of eliciting values and medical information prior to conveying information. The purpose of this approach was to select and individualize information relevant to the treatment decision. In doing so, the oncologists observed used two strategies: "biographical communication" and a "metacommunicative approach." Both strategies could be shown to be effective or to fail depending on patients' characteristics such as their view of the physicians' role and the relevance of value-related information for medical decision-making.

CONCLUSION

In contrast to the conceptual account of SDM, oncologists are in need of patient-related information prior to conveying information. Both strategies observed to elicit such information are in principle justifiable but need to be adapted in accordance with patient preferences and decision-making styles.

IMPLICATIONS FOR PRACTICE

This study showed that knowledge of patients' values and preferences is very important to properly adapt the giving of medical information and to further the process of shared decision-making. Shared decision-making (SDM) trainings should consider different strategies of talking about values. The right strategy depends largely on the patient's preferences in communication. To be aware of the role of values in SDM and to be able to switch communicative strategies might prove to be of particular value. A more systematic evaluation of the patient's decision-making preferences as part of routine procedures in hospitals might help to reduce value-related barriers in communication.

Perceptions of Risk Stratification Workflows in Primary Care

Risk stratification (RS) in primary care is frequently used by policy-makers, payers, and health systems; the process requires risk assessment for adverse health outcomes across a population to assign patients into risk tiers and allow care management (CM) resources to be targeted effectively. Our objective was to understand the approach to and perception of RS in primary care practices. An online survey was developed, tested, and administered to 148 representatives of 37 primary care practices engaged in RS varying in size, location and ownership. The survey assessed practices’ approach to, perception of, and confidence in RS, and its effect on subsequent CM activities. We examined psychometric properties of the survey to determine validity and conducted chi-square analyses to determine the association between practice characteristics and confidence and agreement with risk scores. The survey yielded a 68% response rate (100 respondents). Overall, participants felt moderately confident in their risk scores (range 41–53.8%), and moderately to highly confident in their subsequent CM workflows (range 46–68%). Respondents from small and independent practices were more likely to have higher confidence and agreement with their RS approaches and scores (p < 0.01). Confidence levels were highest, however, when practices incorporated human review into their RS processes (p < 0.05). This trend was not affected by respondents’ professional roles. Additional work from a broad mixed-methods effort will add to our understanding of RS implementation processes and outcomes.