Health decision making: lynchpin of evidence-based practice

Spinal Cord Injury Provider Knowledge and Attitudes Toward Bacteriuria Management and Antibiotic Stewardship

INTRODUCTION

Bacteriuria, either asymptomatic or urinary tract infection, is common in persons with spinal cord injury or disorder (SCI/D). In the Veterans Health Administration (VHA), conflicting clinical practice guidelines make appropriate bacteriuria management and antibiotic stewardship challenging.

OBJECTIVE

To explore SCI/D provider knowledge, attitudes, and teamwork around bacteriuria management during the VHA SCI/D annual examination.

DESIGN

Mixed methods.

SETTING

VHA SCI/D centers.

PARTICIPANTS

SCI/D staff providers and physical medicine and rehabilitation resident physicians.

MAIN OUTCOME MEASUREMENTS

Knowledge, safety, and teamwork scores on bacteriuria management using a validated questionnaire. Themes on barriers and facilitators to bacteriuria management during the SCI/D annual exam, and attitudes toward antibiotic stewardship in general.

RESULTS

We received 84 responses from 344 distributed surveys, with a response rate of 24%. Thirty percent of all participants endorsed incorrect triggers for obtaining a urine culture (change in urine color, cloudiness, or odor). The type of organism identified on culture drove unnecessary antibiotic use; 57% would treat asymptomatic bacteriuria if caused by extended spectrum beta-lactamase Escherichia coli. There were no significant differences between the median (interquartile range [IQR]) knowledge score of the staff providers (70.6 [58.8-82.4]) and the resident physicians (64.7 [58.8-82.4]), but the teamwork climate scores (P = .02) and safety climate scores (P < .01) were higher among staff providers than among resident physicians. Interview analysis identified how the limited recall of content among SCI/D providers of the guidelines for bacteriuria was a potential barrier to their use but attitudes toward guidelines and antibiotic stewardship initiatives were positive.

CONCLUSION

All participants objectively demonstrated actionable gaps in bacteriuria management and expressed uncertainty in their knowledge during qualitative interviews. Through addressing these gaps, we can develop effective antibiotic stewardship programs for the VHA SCI/D system of care.

Protocol for a phase III RCT and economic analysis of two exercise delivery methods in men with PC on ADT

BACKGROUND

Androgen deprivation therapy (ADT) is commonly used to treat prostate cancer. However, side effects of ADT often lead to reduced quality of life and physical function. Existing evidence demonstrates that exercise can ameliorate multiple treatment-related side effects for men on ADT, yet adherence rates are often low. The method of exercise delivery (e.g., supervised group in-centre vs. individual home-based) may be important from clinical and economic perspectives; however, few studies have compared different delivery models. Additionally, long-term exercise adherence and an understanding of predictors of adherence are critical to achieving sustained benefits, but such data are lacking. The primary aim of this multi-centre phase III non-inferiority randomized controlled trial is to determine whether a home-based delivery model is non-inferior to a group-based delivery model in terms of benefits in fatigue and fitness in this population. Two other key aims include examining cost-effectiveness and long-term adherence.

METHODS

Men diagnosed with prostate cancer of any stage, starting or continuing on ADT for at least 6 months, fluent in English, and living close to a study centre are eligible. Participants complete five assessments over 12 months (baseline and every 3 months during the 6-month intervention and 6-month follow-up phases), including a fitness assessment and self-report questionnaires. Biological outcomes are collected at baseline, 6, and 12 months. A total of 200 participants will be randomized in a 1:1 fashion to supervised group training or home-based training supported by smartphones, health coaches, and Fitbit technology. Participants are asked to complete 4 to 5 exercise sessions per week, incorporating aerobic, resistance and flexibility training. Outcomes include fatigue, quality of life, fitness measures, body composition, biological outcomes, and program adherence. Cost information will be obtained using patient diary-based self-report and utilities via the EQ-5D.

DISCUSSION

To disseminate publicly funded exercise programs widely, clinical efficacy and cost-effectiveness have to be demonstrated. The goals of this trial are to provide these data along with an increased understanding of adherence to exercise among men with prostate cancer receiving ADT.

TRIAL REGISTRATION

The trial has been registered at clinicaltrials.gov (Registration # NCT02834416 ). Registration date was June 2, 2016.

Management of Patients With Venous Leg Ulcers: Challenges and Current Best Practice

Introduction It is well documented that the prevalence of venous leg ulcers (VLUs) is increasing, coinciding with an ageing population. Accurate global prevalence of VLUs is difficult to estimate due to the range of methodologies used in studies and accuracy of reporting. (1) Venous ulceration is the most common type of leg ulceration and a significant clinical problem, affecting approximately 1% of the population and 3% of people over 80 years of age (2) in westernised countries. Moreover, the global prevalence of VLUs is predicted to escalate dramatically, as people are living longer, often with multiple comorbidities. Recent figures on the prevalence of VLUs are based on a small number of studies, conducted in Western countries, and the evidence is weak. However, it is estimated that 93% of VLUs will heal in 12 months, and 7% remain unhealed after five years. (3) Furthermore, the recurrence rate within 3 months after wound closure is as high as 70%. (4) (-6) Thus, cost-effective adjunct evidence-based treatment strategies and services are needed to help prevent these ulcers, facilitate healing when they occur and prevent recurrence. The impact of a VLU represents social, personal, financial and psychological costs on the individual and further economic drain on the health-care system. This brings the challenge of providing a standardised leg ulcer service which delivers evidence-based treatment for the patient and their ulcer. It is recognised there are variations in practice and barriers preventing the implementation of best practice. There are patients not receiving appropriate and timely treatment in the initial development of VLUs, effective management of their VLU and preventing recurrence once the VLU has healed. Health-care professionals (HCPs) and organisations must have confidence in the development process of clinical practice guidelines and have ownership of these guidelines to ensure those of the highest quality guide their practice. These systematic judgments can assist in policy development, and decision making, improve communication, reduce errors and improve patient outcomes. There is an abundance of studies and guidelines that are available and regularly updated, however, there is still variation in the quality of the services offered to patients with a VLU. There are also variations in the evidence and some recommendations contradict each other, which can cause confusion and be a barrier to implementation. (7) The difference in health-care organisational structures, management support and the responsibility of VLU management can vary in different countries, often causing confusion and a barrier to seeking treatment. These factors further complicate the guideline implementation process, which is generally known to be a challenge with many diseases. (8).

Finding what works: identification of implementation strategies for the integration of methadone maintenance therapy and HIV services in Vietnam

Background

Integration of methadone maintenance therapy (MMT) and HIV services is an evidence-based intervention (EBI) that benefits HIV care and reduces costs. While MMT/HIV integration is recommended by the World Health Organization and the Centers for Disease Control and Prevention, it is not widely implemented, due to organizational and operational barriers. Our study applied an innovative process to identify implementation strategies to address these barriers.

Methods

Our process was adapted from the Expert Recommendations for Implementing Change (ERIC) protocol and consisted of two main phases. In Phase 1, we conducted 16 in-depth interviews with stakeholders and developed matrices to display barriers to integration. In Phase 2, we selected implementation strategies that addressed the barriers identified in Phase 1 and conducted a poll to vote on the most important and feasible strategies among a panel with expertise in cultural context and implementation science.

Results

Barriers fell into two broad categories: policy and programmatic. At the policy level, barriers included lack of a national mandate, different structures (MMT vs. HIV clinic) for cost reimbursement and staff salaries, and resistance on the part of staff to take on additional tasks without compensation. Programmatic barriers included the need for cross-training in MMT and HIV tasks, staff accountability, and commitment from local leaders. In Phase 2, we focused on programmatic challenges. Based on voting results and iterative dialogue with our expert panel, we selected several implementation strategies in the domains of technical assistance, staff accountability, and local commitment that targeted these barriers.

Conclusions

Key programmatic barriers to MMT/HIV integration in Vietnam may be addressed through implementation strategies that focus on technical assistance, staff accountability, and local commitment. Our process of identifying implementation strategies was simple, low cost, and potentially replicable to other settings.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-016-0420-8) contains supplementary material, which is available to authorized users.

Health Behavior Decision-making in African-American Adults Diagnosed with Schizophrenia

Little is known about the factors that influence health behavior decision-making among people with schizophrenia. The purpose of this qualitative study was to describe the processes used by 10 African-American adults with schizophrenia when making health behavior decisions and identification of perceived barriers and facilitators to health. Three phases of health behavior decision-making were identified: Recognizing Complex Components of Health, Personalizing Components of Health, and Tracking Health Status. Findings may guide clinicians' efforts to improve the health status of patients, as well as influence future research in understanding health behavior decision-making among vulnerable populations.

"It's easier to stick a tube in": a qualitative study to understand clinicians' individual decisions to place urinary catheters in acute medical care

BACKGROUND

Indwelling urinary catheters (IUCs) placed in acute care are a leading cause of healthcare-associated urinary tract infection. Despite initiatives to minimise the placement of IUCs, levels of inappropriate use are still considered unacceptable. IUC practice is difficult to change, and factors influencing clinicians' decisions need to be better understood.

OBJECTIVE

To explore why clinicians decide to place IUCs in acute medical care.

METHODS

We conducted a qualitative study in the emergency department and acute medical wards of a 1200+ bed hospital, undertaking 30 retrospective think aloud and 20 semistructured interviews with nurses and physicians who made the decision to place an IUC. A purposive sample and thematic analysis were used.

RESULTS

Opinions on when an IUC was warranted varied considerably. Inconsistency in decision-making was caused by differing beliefs on when an IUC was appropriate for each clinical indication. Numerous patient and non-patient factors, including clinical setting, resources, patient age and gender and staff workload, also impacted on each decision. Assessing when the benefit of an IUC outweighed the risk could be problematic due to conflicting goals.

CONCLUSIONS

These findings help to explain why clinicians sometimes deviate from IUC best practice guidance and resist interventions to modify practice. In order to engage nurses and physicians in change, interventions to reduce IUC use should acknowledge and respond to the complexity and lack of clarity often faced by clinicians making the decision to place an IUC. However, it is equally important that inconsistencies in IUC-related beliefs are recognised, investigated and, where appropriate, challenged.

Communication of professional literature amongst European Acupuncturists affiliated to the ETCMA (European Traditional Chinese Medicine Association): explorative survey amongst Traditional Chinese Medicine practitioners in Europe

OBJECTIVES

The primary aim of the survey was to explore the information needs and information seeking behavior amongst the ETCMA members concerning professional literature (scientific as well as practical background knowledge).

METHODS

A web-based survey comprising of 18 questions with a total of 25 items was carried out in 15 affiliated associations in 14 countries in June 2012. The survey consisted out of 4 parts: (1) Demographics, (2) Level of interest in and availability of professional literature, (3) Insight, needs and opinions on EBM (Evidence Based Medicine), and (4) Awareness of the science workshop at the TCM Rothenburg Congress.

RESULTS

2590 (25%) from 10,428 members completed the questionnaire, of which 58.8% was female. More than 50% of the respondents from eleven out of fourteen countries indicate an interest in more education on reading scientific literature. Case studies (range 3.19/4-3.86/4) are preferred compared to scientific (range 2.78/4-3.59/4) or philosophical knowledge (range 3.0/4-3.56/4). Exchange with colleagues (range 2.95/4-3.64/4) is preferred compared to deepening knowledge (range 2.57/4-3.05/4) in the theoretical spectrum. 61% has no knowledge of the EBM model and base clinical decisions on personal experience (range 3.47-3.82) and practical skills (range 3.47-3.74) compared to clinical practice guidelines (range 2.6-3.27).

CONCLUSIONS

Due to heterogeneity in structure and size of the affiliated associations no strict conclusions can be made. We can conclude though that TCM practitioners rely mostly on practical knowledge and have less tendency toward more scientifically oriented models like the EBM model. We find this reflected in information needs as well as information seeking behavior patterns.

Clinical Decision-Making in Community Children's Mental Health: Using Innovative Methods to Compare Clinicians With and Without Training in Evidence-Based Treatment

BACKGROUND

Mental health professionals' decision-making practice is an area of increasing interest and importance, especially in the pediatric research and clinical communities.

OBJECTIVE

The present study explored the role of prior training in evidence-based treatments on clinicians' assessment and treatment formulations using case vignettes. Specifically, study aims included using the Naturalistic Decision Making (NDM) cognitive theory to 1) examine potential associations between EBT training and decision-making processes (novice versus expert type), and 2) explore how client and family contextual information affects clinical decision-making.

METHODS

Forty-eight clinicians across two groups (EBT trained=14, Not EBT trained=34) participated. Clinicians were comparable on professional experience, demographics, and discipline. The quasi-experimental design used an analog "think aloud" method where clinicians read case vignettes about a child with disruptive behavior problems and verbalized case conceptualization and treatment planning out-loud. Responses were coded according to NDM theory.

RESULTS

MANOVA results were significant for EBT training status such that EBT trained clinicians' displayed cognitive processes more closely aligned with "expert" decision-makers and non-EBT trained clinicians' decision processes were more similar to "novice" decision-makers, following NDM theory. Non-EBT trained clinicians assigned significantly more diagnoses, provided less detailed treatment plans and discussed fewer EBTs. Parent/family contextual information also appeared to influence decision-making.

CONCLUSION

This study offers a preliminary investigation of the possible broader impacts of EBT training and potential associations with development of expert decision-making skills. Targeting clinicians' decision-making may be an important avenue to pursue within dissemination-implementation efforts in mental health practice.

The telehealth skills, training, and implementation project: an evaluation protocol

Background

Telehealth appears to be an ideal mechanism for assisting rural patients and doctors and medical students/registrars in accessing specialist services. Telehealth is the use of enhanced broadband technology to provide telemedicine and education over distance. It provides accessible support to rural primary care providers and medical educators. A telehealth consultation is where a patient at a general practice, with the assistance of the general practitioner or practice nurse, undertakes a consultation by videoconference with a specialist located elsewhere. Multiple benefits of telehealth consulting have been reported, particularly those relevant to rural patients and health care providers. However there is a paucity of research on the benefits of telehealth to medical education and learning.

Objective

This protocol explains in depth the process that will be undertaken by a collaborative group of universities and training providers in this unique project.

Methods

Training sessions in telehealth consulting will be provided for participating practices and students. The trial will then use telehealth consulting as a real-patient learning experience for students, general practitioner trainees, general practitioner preceptors, and trainees.

Results

Results will be available when the trial has been completed in 2015.

Conclusions

The protocol has been written to reflect the overarching premise that, by building virtual communities of practice with users of telehealth in medical education, a more sustainable and rigorous model can be developed. The Telehealth Skills Training and Implementation Project will implement and evaluate a theoretically driven model of Internet-facilitated medical education for vertically integrated, community-based learning environments

You'll know when you're ready: a qualitative study exploring how patients decide when the time is right for joint replacement surgery

Background

While some studies have identified patient readiness as a key component in their decision whether to have total joint replacement surgery (TJR), none have examined how patients determine their readiness for surgery. The study purpose was to explore the concept of patient readiness and describe the factors patients consider when assessing their readiness for TJR.

Methods

Nine focus groups (4 pre-surgery, 5 post-surgery) were held in four Canadian cities. Participants had been either referred to or seen by an orthopaedic surgeon for TJR or had undergone TJR. The method of analysis was qualitative thematic analysis.

Results

There were 65 participants, 66% female and 34% male, 80% urban, with an average age of 65 years (SD 10). Readiness reflected both the surgeon’s advice that the patient was clinically ready for surgery and the patient’s feeling that they were both mentally and physically ready for surgery. Mental readiness was described as an internal state or feeling of being ready or prepared while physical readiness was described as being physically fit and in good shape for surgery. Factors associated with readiness included: 1) pain: its severity, the ability to cope with it, and how it affected their quality of life; 2) mental preparation; 3) physical preparation; 4) the optimal timing of surgery, including age, anticipated rate of deterioration, prosthesis lifespan and the length of the waiting list.

Conclusions

Patient readiness should be assessed prior to TJR. By assessing patient readiness, health professionals can elucidate and deal with concerns and fears, understand and calibrate expectations, assess coping strategies, and use this information to help determine optimal timing, both before and after the surgical consultation.

Overtreatment of asymptomatic bacteriuria: identifying provider barriers to evidence-based care

BACKGROUND

Inappropriate use of antibiotics to treat asymptomatic bacteriuria (ASB) is a significant contributor to antibiotic overuse in hospitalized patients despite evidence-based guidelines on ASB management. We surveyed whether accurate knowledge of how to manage catheter-associated urine cultures was associated with level of training, familiarity with ASB guidelines, and various cognitive-behavioral constructs.

METHODS

We used a survey to measure respondents' knowledge of how to manage catheter-associated bacteriuria, familiarity with the content of the relevant Infectious Diseases Society of America guidelines, and cognitive-behavioral constructs. The survey was administered to 169 residents and staff providers.

RESULTS

The mean knowledge score was 57.5%, or slightly over one-half of the questions answered correctly. The overall knowledge score improved significantly with level of training (P < .0001). Only 42% of respondents reported greater than minimal recall of ASB guideline contents. Self-efficacy, behavior, risk perceptions, social norms, and guideline familiarity were individually correlated with knowledge score (P < .01). In multivariable analysis, behavior, risk perception, and year of training were correlated with knowledge score (P < .05).

CONCLUSIONS

Knowledge of how to manage catheter-associated bacteriuria according to evidence-based guidelines increases with experience. Addressing both knowledge gaps and relevant cognitive biases early in training may decrease the inappropriate use of antibiotics to treat ASB.

Expert Recommendations for Implementing Change (ERIC): protocol for a mixed methods study

BACKGROUND

Identifying feasible and effective implementation strategies that are contextually appropriate is a challenge for researchers and implementers, exacerbated by the lack of conceptual clarity surrounding terms and definitions for implementation strategies, as well as a literature that provides imperfect guidance regarding how one might select strategies for a given healthcare quality improvement effort. In this study, we will engage an Expert Panel comprising implementation scientists and mental health clinical managers to: establish consensus on a common nomenclature for implementation strategy terms, definitions and categories; and develop recommendations to enhance the match between implementation strategies selected to facilitate the use of evidence-based programs and the context of certain service settings, in this case the U.S. Department of Veterans Affairs (VA) mental health services.

METHODS/DESIGN

This study will use purposive sampling to recruit an Expert Panel comprising implementation science experts and VA mental health clinical managers. A novel, four-stage sequential mixed methods design will be employed. During Stage 1, the Expert Panel will participate in a modified Delphi process in which a published taxonomy of implementation strategies will be used to establish consensus on terms and definitions for implementation strategies. In Stage 2, the panelists will complete a concept mapping task, which will yield conceptually distinct categories of implementation strategies as well as ratings of the feasibility and effectiveness of each strategy. Utilizing the common nomenclature developed in Stages 1 and 2, panelists will complete an innovative menu-based choice task in Stage 3 that involves matching implementation strategies to hypothetical implementation scenarios with varying contexts. This allows for quantitative characterizations of the relative necessity of each implementation strategy for a given scenario. In Stage 4, a live web-based facilitated expert recommendation process will be employed to establish expert recommendations about which implementations strategies are essential for each phase of implementation in each scenario.

DISCUSSION

Using a novel method of selecting implementation strategies for use within specific contexts, this study contributes to our understanding of implementation science and practice by sharpening conceptual distinctions among a comprehensive collection of implementation strategies.

Developing a patient-centered medical home: synopsis and comment on "Patient preferences for shared decisions: a systematic review"

The seventh column on Evidence-Based Behavioral Medicine synopsizes a systematic review by Chewning and colleagues (Pat Educ Couns 86:9-18, 2012) on patient preferences for shared decision-making regarding treatment and screening. A total of 115 studies were included in the final analyses. In 63 % of studies, a majority of patients preferred sharing decisions with their primary care physician, as opposed to delegating health decisions to their provider. A time trend appeared such that in studies published more recently, a greater percentage of patients, particularly cancer patients, preferred sharing decisions. Further research should seek to better understand how the decision making of specific patient populations is influenced by life course changes and secular trends. Longitudinal studies can help to elucidate how patient decision-making preferences evolve over the course of illness and health status changes in different medical conditions.

Conveying genomic recurrence risk estimates to patients with early-stage breast cancer: oncologist perspectives

OBJECTIVE

The development and increased use of genomic profiling has led to refinement of breast cancer treatment. This study sought to examine medical and surgical oncologists' perceptions of factors related to the translation and integration of Oncotype DX® (Genomic Health, Inc., Redwood City, CA, USA) into routine clinical care.

METHODS

Twenty oncologists (10 medical and 10 surgical oncologists) participated in qualitative interviews. Questions centered on the following themes: oncologists' perceptions about the clinical utility of testing, the impact of patient preferences on the decision to test and use results to inform treatment decisions, methods of communicating risk associated with test results to patients, and benefits of and barriers to incorporating testing into multidisciplinary care settings.

RESULTS

Oncologists found Oncotype DX test results useful in their practice but had concerns as well. These included that some oncologists either used testing inappropriately or placed undue emphasis on the results at the expense of other clinical information. The use of intermediate test results, which have less clear clinical implications, incorporating results with patient treatment preferences, and the use of testing in multidisciplinary teams were noted as specific challenges.

CONCLUSION

Oncologists noted several benefits of testing and also many challenges, despite wide dissemination and common use. Education for health providers should include specific training in how to interpret and communicate the uncertainty inherent in genomic tests while integrating patient preferences to inform treatment decision making.

Supporting shared decisions when clinical evidence is low

There is growing interest in shared decision making (SDM) in the United States and globally, at both the clinical and policy levels. SDM is typically employed during "preference-sensitive" decisions, where there is equipoise between treatment options with equal or similar outcomes from a medical standpoint. In these situations, patients' preferences for the possible risks, benefits, and trade-offs between options are central to the decision. However, SDM also may be appropriate in clinical situations besides those in which data demonstrate equipoise. In situations of low evidence, where evidence is conflicting, unavailable or not applicable to an individual patient, supporting SDM can present unique challenges, above and beyond the challenges faced during more standard preference-sensitive decisions. This article discusses challenges in supporting shared decisions when clinical evidence is low, describes strategies that can facilitate SDM despite low evidence, and suggests avenues for future research to explore further these proposed strategies.

Multiple behavior changes in diet and activity: a randomized controlled trial using mobile technology

BACKGROUND

Many patients exhibit multiple chronic disease risk behaviors. Research provides little information about advice that can maximize simultaneous health behavior changes.

METHODS

To test which combination of diet and activity advice maximizes healthy change, we randomized 204 adults with elevated saturated fat and low fruit and vegetable intake, high sedentary leisure time, and low physical activity to 1 of 4 treatments: increase fruit/vegetable intake and physical activity, decrease fat and sedentary leisure, decrease fat and increase physical activity, and increase fruit/vegetable intake and decrease sedentary leisure. Treatments provided 3 weeks of remote coaching supported by mobile decision support technology and financial incentives. During treatment, incentives were contingent on using the mobile device to self-monitor and attain behavioral targets; during follow-up, incentives were contingent only on recording. The outcome was standardized, composite improvement on the 4 diet and activity behaviors at the end of treatment and at 5-month follow-up.

RESULTS

Of the 204 individuals randomized, 200 (98.0%) completed follow-up. The increase fruits/vegetables and decrease sedentary leisure treatments improved more than the other 3 treatments (P < .001). Specifically, daily fruit/vegetable intake increased from 1.2 servings to 5.5 servings, sedentary leisure decreased from 219.2 minutes to 89.3 minutes, and saturated fat decreased from 12.0% to 9.5% of calories consumed. Differences between treatment groups were maintained through follow-up. Traditional dieting (decrease fat and increase physical activity) improved less than the other 3 treatments (P < .001).

CONCLUSIONS

Remote coaching supported by mobile technology and financial incentives holds promise to improve diet and activity. Targeting fruits/vegetables and sedentary leisure together maximizes overall adoption and maintenance of multiple healthy behavior changes.

The role of computerized decision support in reducing errors in selecting medicines for prescription: narrative review

This narrative review includes a summary of research examining prescribing errors, prescription decision making and the role computerized decision support plays in this decision-making process. A reduction in medication prescribing errors, specifically a reduction in the selection of inappropriate medications, is expected to result from the implementation of an effective computerized decision support system. Previous research has investigated the impact of the implementation of electronic systems on medication errors more broadly. This review examines the specific characteristics of decision support systems that may contribute to fewer knowledge-based mistakes in prescribing, and critically appraises the large volume of information available on the decision-making process of selecting medicines for prescription. The results highlight a need for work investigating what decision strategies are used by doctors with different levels of expertise in the prescribing of medications. The nature of the relationship between decision support and decision performance is not well understood and future research is needed to determine the mechanisms by which computerized decision support influences medication selection.

Dynamics of Trust in Medical Decision Making

Background: Patient trust in medical decision makers is a crucial facilitator of effective health care. Greater patient involvement in decision making requires improved understanding of how such trust is built, maintained, and lost in medical contexts. Objective: The study investigates how trust in clinicians is affected by the 4 main diagnostic outcomes proposed by signal detection theory: true positives, true negatives, false positives, and false negatives. Cognitive appraisals of, and affective reactions to, the decisions were measured to investigate the psychological mechanisms underpinning effects on trust. Design: Members of an Internet research panel ( N = 1162) participated in a between-participant experimental study using hypothetical cancer diagnosis scenarios. Results: Overall, correct diagnoses bolstered trust as much as incorrect ones undermined it. Consistent with recent findings in other decision-making domains, trust was not as precarious as generally believed. The influence of decisions and outcomes on trust was mediated through cognitive assessments and affective responses in line with current appraisal theories in psychology. Prior levels of trust in clinicians affected sympathy for doctors, highlighting the role that trust plays in responding to new information. Conclusions: Trust in (hypothetical) clinicians is sensitive to information about their past diagnostic performance. Greater understanding of the cognitive and affective mechanisms by which this occurs may help maintain current high levels of trust. Further research is needed to examine whether findings generalize to real medical decision-making contexts. Clinicians may want to consider the impact their diagnoses have on trust alongside medical and financial considerations.

Contextual decision making and the implementation of clinical guidelines: an example from mental health

PURPOSE

Clinical decision making plays a crucial role in the transformation of science to service. Treatment decisions typically are evaluated by comparing them against norms, such as practice guidelines. An adherence standard has been criticized as inappropriate, but no measurable alternative has been proposed to date. This study develops a new standard of incorporation and a companion matching test, and addresses two questions: (1) Do clinicians incorporate a treatment guideline even when they do not endorse it? (2) If so, do they incorporate the guideline consistently?

METHOD

The study uses the clinical paradigm of treatment-resistant schizophrenia and a published guideline developed at the Yale University Department of Psychiatry that has been soundly rejected in clinical practice. A vignette study was developed, using a four-factor, fully crossed and within-subject design, then administered to 21 volunteer paid psychiatry residents.

RESULTS

The endorsement pattern showed a low concurrence rate and significant apparent inconsistency within subjects. However, the matching test showed a clear relationship between endorsement of the guideline and features of individual vignettes. The matching test demonstrated significant within-subject consistency and accounted for 65% of the endorsement variance.

CONCLUSIONS

Implications are preliminary, given limitations that pertain to the subject population and use of vignettes, the clinical paradigm, and treatment guideline. However, the study's concepts, procedures, and findings may play a valuable role in future transformative initiatives, including training clinicians in the use of clinical guidelines and evaluating the appropriateness of guidelines before their implementation.

A conditional model of evidence-based decision making

RATIONALE, AIMS AND OBJECTIVES

Efforts to describe how individual treatment decisions are informed by systematic knowledge have been hindered by a standard that gauges the quality of clinical decisions by their adherence to guidelines and evidence-based practices. This paper tests a new contextual standard that gauges the incorporation of knowledge into practice and develops a model of evidence-based decision making. Previous work found that the forecasted outcome of a treatment guideline exerts a highly significant influence on how it is used in making decisions. This study proposed that forecasted outcomes affect the recognition of a treatment scenario, and this recognition triggers distinct contextual decision strategies.

METHODS

Twenty-one volunteers from a psychiatric residency programme responded to 64 case vignettes, 16 in each of the four treatment scenarios. The vignettes represented a fully balanced within-subjects design that included guideline switching criteria and patient-specific factors. For each vignette, participants indicated whether they endorsed the guideline's recommendation.

RESULTS

Clinicians used consistent contextual decision strategies in responding to clearly positive or negative forecasts. When forecasts were more ambiguous or risky, their strategies became complex and relatively inconsistent.

CONCLUSION

The results support a three-step model of evidence-based decision making, in which clinicians recognize a decision scenario, apply a simple contextual strategy, then if necessary engage a more complex strategy to resolve discrepancies between general guidelines and specific cases. The paper concludes by noting study limitations and discussing implications of the model for future research in clinical and shared decision making, training and guideline development.