Medical decision making : an international journal of the Society for Medical Decision Making
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The Agency for Health Care Policy and Research (AHCPR) Unstable Angina Practice Guideline recommends outpatient management for patients at low risk and admission to a monitored bed for patients at intermediate-high risk of adverse short-term outcomes, but the clinical consequences of adhering to these recommendations are unclear. ⋯ This analysis supports the practice of discharging low-risk ED patients with symptoms of possible ACS but highlights the need to arrange timely follow-up (or to perform additional risk stratification in the ED prior to discharge). It also confirms the benefit of admitting ED patients with intermediate- to high-risk characteristics to a monitored bed.
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Reducing excess duration of antibiotic therapy is a strategy for limiting the spread of antibiotic resistance, but altering physician practice to accomplish this requires knowledge of the factors that influence physician antibiotic choice. The authors aimed to quantify physician willingness to trade between 4 attributes of antibiotic therapies: different therapy durations, failure rates, dosing frequencies, and days of diarrhea as a side effect when treating acute uncomplicated pyelonephritis. ⋯ Antibiotic choice is most influenced by physicians' desires to limit treatment failure and side effects, although physicians were willing to accept increases in treatment failure to obtain reduced days of diarrhea as a side effect. Because shorter-course therapy is frequently associated with fewer side effects, efforts to encourage physicians to choose shorter treatment durations should include mention of reduced treatment-associated side effects.
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Phase 2 clinical trials are undertaken to provide evidence of treatment efficacy and safety. A test statistic that accounts for individual patient risk in the patient population is proposed and applied to a phase 2 clinical trial for castrate metastatic prostate cancer. The test statistic is computed to compare, for each patient, the observed 2-year survival outcome to the predicted 2-year survival probability. ⋯ The test result is compared to the score test, the binomial exact test, and Fisher's exact test, all of which use the average 2-year survival probability in the population as the parameter of interest. The results demonstrate the benefit of risk adjustment in determining treatment efficacy in a single-arm phase 2 trial. By adjusting for patient risk, this method can provide a more precise assessment of phase 2 treatment efficacy, thereby improving the decision whether to proceed to a phase 3 clinical trial.