A concept-based framework for retrieving evidence to support emergency physician decision making at the point of care

The goal of evidence-based medicine is to uniformly apply evidence gained from scientific research to aspects of clinical practice. In order to achieve this goal, new applications that integrate increasingly disparate health care information resources are required. Access to and provision of evidence must be seamlessly integrated with existing clinical workflow and evidence should be made available where it is most often required - at the point of care. In this paper we address these requirements and outline a concept-based framework that captures the context of a current patient-physician encounter by combining disease and patient-specific information into a logical query mechanism for retrieving relevant evidence from the Cochrane Library. Returned documents are organized by automatically extracting concepts from the evidence-based query to create meaningful clusters of documents which are presented in a manner appropriate for point of care support. The framework is currently being implemented as a prototype software agent that operates within the larger context of a multi-agent application for supporting workflow management of emergency pediatric asthma exacerbations. © 2008 Springer-Verlag Berlin Heidelberg.

Shared decision-making in mental health care : a user perspective on decisional needs in community-based services

BACKGROUND: Shared decision-making (SDM) is an emergent research topic in the field of mental health care and is considered to be a central component of a recovery-oriented system. Despite the evidence suggesting the benefits of this change in the power relationship between users and practitioners, the method has not been widely implemented in clinical practice. OBJECTIVE: The objective of this study was to investigate decisional and information needs among users with mental illness as a prerequisite for the development of a decision support tool aimed at supporting SDM in community-based mental health services in Sweden. METHODS: Three semi-structured focus group interviews were conducted with 22 adult users with mental illness. The transcribed interviews were analyzed using a directed content analysis. This method was used to develop an in-depth understanding of the decisional process as well as to validate and conceptually extend Elwyn et al.'s model of SDM. RESULTS: The model Elwyn et al. have created for SDM in somatic care fits well for mental health services, both in terms of process and content. However, the results also suggest an extension of the model because decisions related to mental illness are often complex and involve a number of life domains. Issues related to social context and individual recovery point to the need for a preparation phase focused on establishing cooperation and mutual understanding as well as a clear follow-up phase that allows for feedback and adjustments to the decision-making process. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The current study contributes to a deeper understanding of decisional and information needs among users of community-based mental health services that may reduce barriers to participation in decision-making. The results also shed light on attitudinal, relationship-based, and cognitive factors that are important to consider in adapting SDM in the mental health system.

Does stakeholder orientation matter? : empirical evidence about power and influence in local government decision-making

Despite being in the business agenda for almost thirty years, stakeholder management is still an under explored field in the public management context. The investigation presented in this doctoral thesis aims to ensure that stakeholder management is a useful technique able to raise issues about power and interests to public organisation’s strategic management processes. Stakeholder theory is tested in an exploratory study carried out with English Local Authorities whose focus is place on decision-making. The findings derive from two distinct and complementary studies: a cross-sectional survey undertaken with chief executives based on the quantitative approach and a qualitative investigation based on cross-sectional case studies and in-depth interviews of validation. While the first study aimed to produce a reliable and comprehensive list of stakeholders able to raise issues in decision-making, the second study aimed to depict the arena in which decision-making comes about. The findings indicate that local government decision-making is a multistakeholder process in which influences are exerted according to stakeholders’ power and interest. The findings also indicate that local government managers should take into account these tissues to avoid losing resources and legitimacy from its environmental supporters. Another issue raised by the investigation is related to the ethics upon which these types of relationships are based. According to the evidence gathered throughout the investigation, the formal model of accountability does not cover the whole set of stakeholders engaged in the process.

Providing evidence-based answers to clinical questions - A pilot information service for general practitioners

Objective: To pilot a clinical information service for general practitioners. Methods: A representative sample of 31 GPs was invited to submit clinical questions to a local academic department of general practice. Their views on the service and the usefulness of the information were obtained by telephone interview. Results: Over one month, nine GPs (29% of the sample, 45% of those stating an interest), submitted 20 enquiries comprising 45 discrete clinical questions. The median time to search for evidence, appraise it and write answers to each enquiry was 2.5 hours (range, 1.0-7.4 hours). The median interval between receipt of questions and dispatch of answers was 3 clays (range, 1-12 days). Conclusions: The GPs found the answers useful in clinical decision making; in four out of 20 cases patient management was altered.

Ways of using evidence-based medicine in general practice

General practitioners wanting to practise evidence-based medicine (EBM) are constrained by time factors and the great diversity of clinical problems they deal with. They need experience in knowing what questions to ask, in locating and evaluating the evidence, and in applying it. Conventional searching for the best evidence can be achieved in daily general practice. Sometimes the search can be performed during the consultation, but more often it can be done later and the patient can return for the result. Case-based journal clubs provide a supportive environment for GPs to work together to find the best evidence at regular meetings. An evidence-based literature search service is being piloted to enhance decision-making for individual patients. A central facility provides the search and interprets the evidence in relation to individual cases. A request form and a results format make the service akin to pathology testing or imaging. Using EBM in general practice appears feasible. Major difficulties still exist before it can be practised by all GPs, but it has the potential to change the way doctors update their knowledge.

Whither our Art? Clinical Wisdom & Evidence-based Medicine

The relationship between evidence-based medicine (EBM) and clinical judgement is the subject of conceptual and practical dispute. For example, EBM and clinical guidelines are seen to increasingly dominate medical decision-making at the expense of other, human elements, and to threaten the art of medicine. Clinical wisdom always remains open to question. We want to know why particular beliefs are held, and the epistemological status of claims based in wisdom or experience. The paper critically appraises a number of claims and distinctions, and attempts to clarify the connections between EBM, clinical experience and judgement, and the objective and evaluative categories of medicine. I conclude that to demystify clinical wisdom is not to devalue it. EBM ought not be conceived as needing to be limited or balanced by clinical wisdom, since if its language is translatable into terms comprehensible and applicable to individuals, it helps constitute clinical wisdom. Failure to appreciate this constitutive relation will help perpetuate medical paternalism and delay the adoption of properly evidence-based practice, which would be both unethical and unwise.

Perceptions of evidence-based practice: A survey of Australian occupational therapists

Evidence-based practice (EBP) requires clinicians to access, appraise and integrate research literature with clinical experience and clients' perspectives. Currently, little is known about occupational therapists' attitudes to EBP, their perception of implementation barriers or their educational needs. A questionnaire reflecting these issues was sent to a proportionate random sample of 1491 members of the national professional occupational therapy association, OT AUSTRALIA. The questionnaire was completed by 649 (44%) participants. Occupational therapists were positive about EBP with most (96%) agreeing that EBP is important to occupational therapy. Although 56% used research to make clinical decisions, more relied on clinical experience (96%), information from continuing education (82%) and colleagues (80%). Lack of time, evidence and skills were identified as the main barriers to the implementation of EBP. Over half (52%) expressed strong interest in EBP skills training, and most (80%) indicated an interest in the availability of brief summaries of evidence. Targeted educational initiatives, resources and systems are needed to support EBP in occupational therapy.

Ambient intelligence in emotion based ubiquitous decision making

As the time goes on, it is a question of common sense to involve in the process of decision making people scattered around the globe. Groups are created in a formal or informal way, exchange ideas or engage in a process of argumentation and counterargumentation, negotiate, cooperate, collaborate or even discuss techniques and/or methodologies for problem solving. In this work it is proposed an agent-based architecture to support a ubiquitous group decision support system, i.e. based on the concept of agent, which is able to exhibit intelligent, and emotional-aware behaviour, and support argumentation, through interaction with individual persons or groups. It is enforced the paradigm of Mixed Initiative Systems, so the initiative is to be pushed by human users and/or intelligent agents.

Personality, emotion, and mood in agent-based group decision making

Group decision making plays an important role in organizations, especially in the present-day economy that demands high-quality, yet quick decisions. Group decision-support systems (GDSSs) are interactive computer-based environments that support concerted, coordinated team efforts toward the completion of joint tasks. The need for collaborative work in organizations has led to the development of a set of general collaborative computer-supported technologies and specific GDSSs that support distributed groups (in time and space) in various domains. However, each person is unique and has different reactions to various arguments. Many times a disagreement arises because of the way we began arguing, not because of the content itself. Nevertheless, emotion, mood, and personality factors have not yet been addressed in GDSSs, despite how strongly they influence results. Our group’s previous work considered the roles that emotion and mood play in decision making. In this article, we reformulate these factors and include personality as well. Thus, this work incorporates personality, emotion, and mood in the negotiation process of an argumentbased group decision-making process. Our main goal in this work is to improve the negotiation process through argumentation using the affective characteristics of the involved participants. Each participant agent represents a group decision member. This representation lets us simulate people with different personalities. The discussion process between group members (agents) is made through the exchange of persuasive arguments. Although our multiagent architecture model4 includes two types of agents—the facilitator and the participant— this article focuses on the emotional, personality, and argumentation components of the participant agent.

Context-aware emotion-based model for group decision making

Involving groups in important management processes such as decision making has several advantages. By discussing and combining ideas, counter ideas, critical opinions, identified constraints, and alternatives, a group of individuals can test potentially better solutions, sometimes in the form of new products, services, and plans. In the past few decades, operations research, AI, and computer science have had tremendous success creating software systems that can achieve optimal solutions, even for complex problems. The only drawback is that people don’t always agree with these solutions. Sometimes this dissatisfaction is due to an incorrect parameterization of the problem. Nevertheless, the reasons people don’t like a solution might not be quantifiable, because those reasons are often based on aspects such as emotion, mood, and personality. At the same time, monolithic individual decisionsupport systems centered on optimizing solutions are being replaced by collaborative systems and group decision-support systems (GDSSs) that focus more on establishing connections between people in organizations. These systems follow a kind of social paradigm. Combining both optimization- and socialcentered approaches is a topic of current research. However, even if such a hybrid approach can be developed, it will still miss an essential point: the emotional nature of group participants in decision-making tasks. We’ve developed a context-aware emotion based model to design intelligent agents for group decision-making processes. To evaluate this model, we’ve incorporated it in an agent-based simulator called ABS4GD (Agent-Based Simulation for Group Decision), which we developed. This multiagent simulator considers emotion- and argument based factors while supporting group decision-making processes. Experiments show that agents endowed with emotional awareness achieve agreements more quickly than those without such awareness. Hence, participant agents that integrate emotional factors in their judgments can be more successful because, in exchanging arguments with other agents, they consider the emotional nature of group decision making.

Decision making processes based on innovation indicators: which implications for technology assessment?

Based on the report for “Project IV” unit of the PhD programme on Technology Assessment. This thesis research has the supervision of António Moniz (FCT-UNL and ITAS-KIT) and Manuel Laranja (ISEG-UTL). Other members of the thesis committee are Stefan Kuhlmann (Twente University), Leonhard Hennen (Karlsruhe Institute of Technology-ITAS), Tiago Santos Pereira (Universidade de Coimbra/CES) and Cristina Sousa (FCT-UNL).

Effects of stress on economic decision-making: Evidence from laboratory experiments

The ways in which preferences respond to the varying stress of economic environments is a key question for behavioral economics and public policy. We conducted a laboratory experiment to investigate the effects of stress on financial decision making among individuals aged 50 and older. Using the cold pressor task as a physiological stressor, and a series of intelligence tests as cognitive stressors, we find that stress increases subjective discounting rates, has no effect on the degree of risk-aversion, and substantially lowers the effort individuals make to learn about financial decisions.

The impact of information on decision-making in palliative care

Résumé Ce travail vise à clarifier les résultats contradictoires de la littérature concernant les besoins des patients d'être informés et de participer à la prise de décision. La littérature insiste sur le contenu de l'information comme base de la prise de décision, bien qu'il existe des preuves que d'autres contenus sont importants pour les patients. La thèse essaie en outre d'identifier des possibilités de mieux répondre aux préférences d'information et de participation des patients. Les travaux ont porté en particulier sur les soins palliatifs. Une analyse de la littérature donne un aperçu sur les soins palliatifs, sur l'information des patients et sur leur participation à la prise de décisions thérapeutiques. Cette analyse résume les résultats d'études précédentes et propose un: modèle théorique d'information, de prise de décision et de relation entre ces deux domaines. Dans le cadre de ce travail, deux études empiriques ont utilisé des questionnaires écrits adressés à des personnes privées et à des professionnels de la santé, couvrant la Suisse et le Royaume Uni, pour identifier d'éventuelles différences entre ces deux pays. Les enquêtes ont été focalisées sur des patients souffrant de cancer du poumon. Les instruments utilisés pour ces études proviennent de la littérature afin de les rendre comparables. Le taux de réponse aux questionnaires était de 30-40%. La majorité des participants aux enquêtes estime que les patients devraient: - collaborer à la prise de décision quant à leur traitement - recevoir autant d'information que possible, positive aussi bien que négative - recevoir toutes les informations mentionnées dans le questionnaire (concernant la maladie, le diagnostic et les traitements), tenant compte de la diversité des priorités des patients - être soutenus par des professionnels de la santé, leur famille, leurs amis et/ou les personnes souffrant de la même maladie En plus, les participants aux enquêtes ont identifié divers contenus de l'information aux patients souffrant d'une maladie grave. Ces contenus comprennent entre autres: - L'aide à la prise de décision concernant le traitement - la possibilité de maintenir le contrôle de la situation - la construction d'une relation entre le patient et le soignant - l'encouragement à faire des projets d'avenir - l'influence de l'état émotionnel - l'aide à la compréhension de la maladie et de son impact - les sources potentielles d'états confusionnels et d'états anxieux La plupart des contenus proposés sont positifs. Les résultats suggèrent la coexistence possible de différents contenus à un moment donné ainsi que leur changement au cours du temps. Un modèle est ensuite développé et commenté pour présenter le diagnostic d'une maladie grave. Ce modèle est basé sur la littérature et intègre les résultats des études empiriques réalisées dans le cadre de ce travail. Ce travail analyse également les sources préférées d'information et de soutien, facteurs qui peuvent influencer ou faire obstacle aux préférences d'information et de participation. Les deux groupes de participants considèrent les médecins spécialistes comme la meilleure source d'information. En ce qui concerne le soutien, les points de vue divergent entre les personnes privées et les professionnels de la santé: généralement, les rôles de soutien semblent peu définis parmi les professionnels. Les barrières à l'information adéquate du patient apparaissent fréquemment liées aux caractéristiques des professionnels et aux problèmes d'organisation. Des progrès dans ce domaine contribueraient à améliorer les soins fournis aux patients. Finalement, les limites des études empiriques sont discutées. Celles-ci comprennent, entre autres, la représentativité restreinte des participants et les objections de certains groupes de participants à quelques détails des questionnaires. Summary The present thesis follows a call from the current body of literature to better understand patient needs for information and for participation in decision-making, as previous research findings had been contradictory. Information so far seems to have been considered essentially as a means to making treatment decisions, despite certain evidence that it may have a number of other values to patients. Furthermore, the thesis aims to identify ways to optimise meeting patient preferences for information and participation in treatment decisions. The current field of interest is palliative care. An extensive literature review depicts the background of current concepts of palliative care, patient information and patient involvement into treatment decisions. It also draws together results from previous studies and develops a theoretical model of information, decision-making, and the relationship between them. This is followed by two empirical studies collecting data from members of the general public and health care professionals by means of postal questionnaires. The professional study covers both Switzerland and the United Kingdom in order to identify possible differences between countries. Both studies focus on newly diagnosed lung cancer patients. The instruments used were taken from the literature to make them comparable. The response rate in both surveys was 30-40%, as expected -sufficient to allow stastical tests to be performed. A third study, addressed to lung cancer patients themselves, turned out to require too much time within the frame available. A majority of both study populations thought that patients should: - have a collaborative role in treatment-related decision-making -receive as much information as possible, good or bad - receive all types of information mentioned in the questionnaire (about illness, tests, and treatment), although priorities varied across the study populations - be supported by health professionals, family members, friends and/or others with the same illness Furthermore they identified various 'meanings' information may have to patients with a serious illness. These included: - being an aid in treatment-related decision-making - allowing control to be maintained over the situation - helping the patient-professional relationship to be constructed - allowing plans to be made - being positive for the patient's emotional state - helping the illness and its impact to be understood - being a source of anxiety - being a potential source of confusion to the patient Meanings were mostly positive. It was suggested that different meanings could co-exist at a given time and that they might change over time. A model of coping with the disclosure of a serious diagnosis is then developped. This model is based on existing models of coping with threatening events, as takeñ from the literature [ref. 77, 78], and integrates findings from the empirical studies. The thesis then analyses the remaining aspects apparent from the two surveys. These range from the identification of preferred information and support providers to factors influencing or impeding information and participation preferences. Specialist doctors were identified by both study populations as the best information providers whilst with regard to support provision views differed between the general public and health professionals. A need for better definition of supportive roles among health care workers seemed apparent. Barriers to information provision often seem related to health professional characteristics or organisational difficulties, and improvements in the latter field could well help optimising patient care. Finally, limitations of the studies are discussed, including questions of representativness of certain results and difficulties with or objections against questionnaire details by some groups of respondents.