Clinical utility of a Web-enabled risk-assessment and clinical decision support program.

PURPOSE: Risk-stratified guidelines can improve quality of care and cost-effectiveness, but their uptake in primary care has been limited. MeTree, a Web-based, patient-facing risk-assessment and clinical decision support tool, is designed to facilitate uptake of risk-stratified guidelines. METHODS: A hybrid implementation-effectiveness trial of three clinics (two intervention, one control). PARTICIPANTS: consentable nonadopted adults with upcoming appointments. PRIMARY OUTCOME: agreement between patient risk level and risk management for those meeting evidence-based criteria for increased-risk risk-management strategies (increased risk) and those who do not (average risk) before MeTree and after. MEASURES: chart abstraction was used to identify risk management related to colon, breast, and ovarian cancer, hereditary cancer, and thrombosis. RESULTS: Participants = 488, female = 284 (58.2%), white = 411 (85.7%), mean age = 58.7 (SD = 12.3). Agreement between risk management and risk level for all conditions for each participant, except for colon cancer, which was limited to those <50 years of age, was (i) 1.1% (N = 2/174) for the increased-risk group before MeTree and 16.1% (N = 28/174) after and (ii) 99.2% (N = 2,125/2,142) for the average-risk group before MeTree and 99.5% (N = 2,131/2,142) after. Of those receiving increased-risk risk-management strategies at baseline, 10.5% (N = 2/19) met criteria for increased risk. After MeTree, 80.7% (N = 46/57) met criteria. CONCLUSION: MeTree integration into primary care can improve uptake of risk-stratified guidelines and potentially reduce "overuse" and "underuse" of increased-risk services.Genet Med 18 10, 1020-1028.

DEMOCRACY ISN'T THAT SMART (BUT WE CAN MAKE IT SMARTER): ON LANDEMORE'S DEMOCRATIC REASON

Copyright © Cambridge University Press 2016In her recent book, Democratic Reason, Hélène Landemore argues that, when evaluated epistemically, “a democratic decision procedure is likely to be a better decision procedure than any non-democratic decision procedures, such as a council of experts or a benevolent dictator” (p. 3). Landemore's argument rests heavily on studies of collective intelligence done by Lu Hong and Scott Page. These studies purport to show that cognitive diversity – differences in how people solve problems – is actually more important to overall group performance than average individual ability – how smart the individual members are. Landemore's argument aims to extrapolate from these results to the conclusion that democracy is epistemically better than any non-democratic rival. I argue here that Hong and Page's results actually undermine, rather than support, this conclusion. More specifically, I argue that the results do not show that democracy is better than any non-democratic alternative, and that in fact, they suggest the opposite – that at least some non-democratic alternatives are likely to epistemically outperform democracy.