The influence of patient's age on clinical decision-making about coronary heart disease in the USA and the UK

This paper examines UK and US primary care doctors' decision-making about older (aged 75 years) and midlife (aged 55 years) patients presenting with coronary heart disease (CHD). Using an analytic approach based on conceptualising clinical decision-making as a classification process, it explores the ways in which doctors' cognitive processes contribute to ageism in health-care at three key decision points during consultations. In each country, 56 randomly selected doctors were shown videotaped vignettes of actors portraying patients with CHD. The patients' ages (55 or 75 years), gender, ethnicity and social class were varied systematically. During the interviews, doctors gave free-recall accounts of their decision-making. The results do not establish that there was substantial ageism in the doctors' decisions, but rather suggest that diagnostic processes pay insufficient attention to the significance of older patients' age and its association with the likelihood of co-morbidity and atypical disease presentations. The doctors also demonstrated more limited use of 'knowledge structures' when diagnosing older than midlife patients. With respect to interventions, differences in the national health-care systems rather than patients' age accounted for the differences in doctors' decisions. US doctors were significantly more concerned about the potential for adverse outcomes if important diagnoses were untreated, while UK general practitioners cited greater difficulty in accessing diagnostic tests.

Classifying clinical decision making:a unifying approach

This is the first of two linked papers exploring decision making in nursing which integrate research evidence from different clinical and academic disciplines. Currently there are many decision-making theories, each with their own distinctive concepts and terminology, and there is a tendency for separate disciplines to view their own decision-making processes as unique. Identifying good nursing decisions and where improvements can be made is therefore problematic, and this can undermine clinical and organizational effectiveness, as well as nurses' professional status. Within the unifying framework of psychological classification, the overall aim of the two papers is to clarify and compare terms, concepts and processes identified in a diversity of decision-making theories, and to demonstrate their underlying similarities. It is argued that the range of explanations used across disciplines can usefully be re-conceptualized as classification behaviour. This paper explores problems arising from multiple theories of decision making being applied to separate clinical disciplines. Attention is given to detrimental effects on nursing practice within the context of multidisciplinary health-care organizations and the changing role of nurses. The different theories are outlined and difficulties in applying them to nursing decisions highlighted. An alternative approach based on a general model of classification is then presented in detail to introduce its terminology and the unifying framework for interpreting all types of decisions. The classification model is used to provide the context for relating alternative philosophical approaches and to define decision-making activities common to all clinical domains. This may benefit nurses by improving multidisciplinary collaboration and weakening clinical elitism.

Investigating the influence of African American and African Caribbean race on primary care doctors' decision making about depression

This paper explores differences in how primary care doctors process the clinical presentation of depression by African American and African-Caribbean patients compared with white patients in the US and the UK. The aim is to gain a better understanding of possible pathways by which racial disparities arise in depression care. One hundred and eight doctors described their thought processes after viewing video recorded simulated patients presenting with identical symptoms strongly suggestive of depression. These descriptions were analysed using the CliniClass system, which captures information about micro-components of clinical decision making and permits a systematic, structured and detailed analysis of how doctors arrive at diagnostic, intervention and management decisions. Video recordings of actors portraying black (both African American and African-Caribbean) and white (both White American and White British) male and female patients (aged 55 years and 75 years) were presented to doctors randomly selected from the Massachusetts Medical Society list and from Surrey/South West London and West Midlands National Health Service lists, stratified by country (US v.UK), gender, and years of clinical experience (less v. very experienced). Findings demonstrated little evidence of bias affecting doctors' decision making processes, with the exception of less attention being paid to the potential outcomes associated with different treatment options for African American compared with White American patients in the US. Instead, findings suggest greater clinical uncertainty in diagnosing depression amongst black compared with white patients, particularly in the UK. This was evident in more potential diagnoses. There was also a tendency for doctors in both countries to focus more on black patients' physical rather than psychological symptoms and to identify endocrine problems, most often diabetes, as a presenting complaint for them. This suggests that doctors in both countries have a less well developed mental model of depression for black compared with white patients. © 2014 The Authors.

Investigating mental health risk assessment in primary care and the potential role of a structured decision support tool, GRiST

Aim: To explore current risk assessment processes in general practice and Improving Access to Psychological Therapies (IAPT) services, and to consider whether the Galatean Risk and Safety Tool (GRiST) can help support improved patient care. Background: Much has been written about risk assessment practice in secondary mental health care, but little is known about how it is undertaken at the beginning of patients' care pathways, within general practice and IAPT services. Methods: Interviews with eight general practice and eight IAPT clinicians from two primary care trusts in the West Midlands, UK, and eight service users from the same region. Interviews explored current practice and participants' views and experiences of mental health risk assessment. Two focus groups were also carried out, one with general practice and one with IAPT clinicians, to review interview findings and to elicit views about GRiST from a demonstration of its functionality. Data were analysed using thematic analysis. Findings Variable approaches to mental health risk assessment were observed. Clinicians were anxious that important risk information was being missed, and risk communication was undermined. Patients felt uninvolved in the process, and both clinicians and patients expressed anxiety about risk assessment skills. Clinicians were positive about the potential for GRiST to provide solutions to these problems. Conclusions: A more structured and systematic approach to risk assessment in general practice and IAPT services is needed, to ensure important risk information is captured and communicated across the care pathway. GRiST has the functionality to support this aspect of practice.

An efficient knowledge transfer solution to a novel SMDP formalization of a broker's decision problem

This paper introduces a new technique for optimizing the trading strategy of brokers that autonomously trade in re- tail and wholesale markets. Simultaneous optimization of re- tail and wholesale strategies has been considered by existing studies as intractable. Therefore, each of these strategies is optimized separately and their interdependence is generally ignored, with resulting broker agents not aiming for a glob- ally optimal retail and wholesale strategy. In this paper, we propose a novel formalization, based on a semi-Markov deci- sion process (SMDP), which globally and simultaneously op- timizes retail and wholesale strategies. The SMDP is solved using hierarchical reinforcement learning (HRL) in multi- agent environments. To address the curse of dimensionality, which arises when applying SMDP and HRL to complex de- cision problems, we propose an ecient knowledge transfer approach. This enables the reuse of learned trading skills in order to speed up the learning in new markets, at the same time as making the broker transportable across market envi- ronments. The proposed SMDP-broker has been thoroughly evaluated in two well-established multi-agent simulation en- vironments within the Trading Agent Competition (TAC) community. Analysis of controlled experiments shows that this broker can outperform the top TAC-brokers. More- over, our broker is able to perform well in a wide range of environments by re-using knowledge acquired in previously experienced settings.

The Fuzzy-Neuro Classifier for Decision Support

This paper aims at development of procedures and algorithms for application of artificial intelligence tools to acquire process and analyze various types of knowledge. The proposed environment integrates techniques of knowledge and decision process modeling such as neural networks and fuzzy logic-based reasoning methods. The problem of an identification of complex processes with the use of neuro-fuzzy systems is solved. The proposed classifier has been successfully applied for building one decision support systems for solving managerial problem.

On the Structure of Spatial Branching Processes

The paper is a contribution to the theory of branching processes with discrete time and a general phase space in the sense of [2]. We characterize the class of regular, i.e. in a sense sufficiently random, branching processes (Φk) k∈Z by almost sure properties of their realizations without making any assumptions about stationarity or existence of moments. This enables us to classify the clans of (Φk) into the regular part and the completely non-regular part. It turns out that the completely non-regular branching processes are built up from single-line processes, whereas the regular ones are mixtures of left-tail trivial processes with a Poisson family structure.

Situational Script Management of Business Processes with Changeable Structure

In the presented work the problem of management business-processes with changeable structure is considered and situational based approach to its decision is offered. The approach is based on situational model of management business-process according to which process is represented as a set of situations. The script defining necessary actions is connected with each situation. Management of process is carried out by means of the rules formalizing functional requirements to processes.

Research of Influence of Medication Preparations on the Process of Renewal of the Broken Equilibrium of Man Organism on the Doctor of Phytotherapy Workstation

In the given work by authors new approach to the exposure of degree of influencing of medications of vegetable origin in a time of renewal of broken equilibrium of man organism is offered. During realization of the given approach it is suggested to use the mathematical vehicle of.

How organizational cognitive neuroscience can deepen understanding of managerial decision-making:a review of the recent literature and future directions

There is growing interest in exploring the potential links between human biology and management and organization studies, which is bringing greater attention to bear on the place of mental processes in explaining human behaviour and effectiveness. The authors define this new field as organizational cognitive neuroscience (OCN), which is in the exploratory phase of its emergence and diffusion. It is clear that there are methodological debates and issues associated with OCN research, and the aim of this paper is to illuminate these concerns, and provide a roadmap for rigorous and relevant future work in the area. To this end, the current reach of OCN is investigated by the systematic review methodology, revealing three clusters of activity, covering the fields of economics, marketing and organizational behaviour. Among these clusters, organizational behaviour seems to be an outlier, owing to its far greater variety of empirical work, which the authors argue is largely a result of the plurality of research methods that have taken root within this field. Nevertheless, all three clusters contribute to a greater understanding of the biological mechanisms that mediate choice and decision-making. The paper concludes that OCN research has already provided important insights regarding the boundaries surrounding human freedom to act in various domains and, in turn, self-determination to influence the workplace. However, there is much to be done, and emerging research of significant interest is highlighted.

An investigation of Albanian EFL teachers' decision-making in their use of CLT-oriented textbooks

Against a backdrop of ongoing educational reforms that seek to introduce Communicative Language Teaching (CLT) in Albanian primary and secondary state schools, Albanian teachers, among others, are officially required to use communication-based textbooks in their classes. Authorities in a growing number of countries that are seeking to improve and westernise their educational systems are also using communication-based textbooks as agents of change. Behind these actions, there is the commonly held belief that textbooks can be used to support teacher learning as they provide a visible framework teachers can follow. Communication-based textbooks are used in thousands of EFL classrooms around the world to help teachers to “fully understand and routinize change” (Hutchinson and Torres, 1994:323). However, empirical research on the role materials play in the classroom, and in particular the role of textbook as an agent of change, is still very little, and what does exist is rather inconclusive. This study aims to fulfill this gap. It is predominately a qualitative investigation into how and why four Albanian EFL teachers use Western teaching resources in their classes. Aiming at investigating the decision-making processes that teachers go through in their teaching, and specifically at investigating the relationship between Western-published textbooks, teachers’ decision making, and teachers’ classroom delivery, the current study contributes to an extensive discussion on the development of communicative L2 teaching concepts and methods, teacher decision making, as well as a growing discussion on how best to make institutional reforms effective, particularly in East-European ex-communist countries and in other developing countries. Findings from this research indicate that, prompted by the content of Western-published textbooks, the four research participants, who had received little formal training in CLT teaching, accommodated some communicative teaching behaviours into their teaching. The use of communicative textbooks, however, does not seem to account for radical, methodological changes in teachers’ practices. Teacher cognitions based on teachers’ previous learning experience are likely to act as a lens through which teachers judge classroom realities. As such, they shape, to a great degree, the decisions teachers make regarding the use of Western-published textbooks in their classes.

A Stochastic Control Approach to a Parabolic Equation, Reciprocal Processes

2000 Mathematics Subject Classi cation: 49L60, 60J60, 93E20.

A Note on the Extinction Problem for Controlled Multitype Branching Processes

2000 Mathematics Subject Classification: 60J80, 60J10.

On the Equality of Sharp and Germ - Fields for Gaussian Processes and Fields

2000 Mathematics Subject Classification: 60G15, 60G60; secondary 31B15, 31B25, 60H15

Variational Markov chain Monte Carlo for Bayesian smoothing of non-linear diffusions

In this paper we develop set of novel Markov Chain Monte Carlo algorithms for Bayesian smoothing of partially observed non-linear diffusion processes. The sampling algorithms developed herein use a deterministic approximation to the posterior distribution over paths as the proposal distribution for a mixture of an independence and a random walk sampler. The approximating distribution is sampled by simulating an optimized time-dependent linear diffusion process derived from the recently developed variational Gaussian process approximation method. The novel diffusion bridge proposal derived from the variational approximation allows the use of a flexible blocking strategy that further improves mixing, and thus the efficiency, of the sampling algorithms. The algorithms are tested on two diffusion processes: one with double-well potential drift and another with SINE drift. The new algorithm's accuracy and efficiency is compared with state-of-the-art hybrid Monte Carlo based path sampling. It is shown that in practical, finite sample applications the algorithm is accurate except in the presence of large observation errors and low to a multi-modal structure in the posterior distribution over paths. More importantly, the variational approximation assisted sampling algorithm outperforms hybrid Monte Carlo in terms of computational efficiency, except when the diffusion process is densely observed with small errors in which case both algorithms are equally efficient. © 2011 Springer-Verlag.