Medical decision making : an international journal of the Society for Medical Decision Making
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Physicians sometimes order diagnostic tests to reduce the risk of malpractice liability. The authors develop an expected-utility model that links a rational physician's concerns about malpractice liability to increases in the use of diagnostic tests and use this model to assess the effects of defensive testing on patients' interests. To do so, they adapt the threshold approach to clinical decision making to incorporate the physician's interests, focusing on 1) the effect of the physician's expected liability risks and 2) the effect of any expected liability reduction due to diagnostic testing. ⋯ Although the defensive use of diagnostic tests improves clinical outcomes for some patients, it worsens clinical outcomes for others. Moreover, defensive testing worsens the expected outcomes of all patients whose clinical strategies are changed. Physicians should realize that defensive testing necessarily reduces the overall quality of patient care.
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Failure of three decision rules to predict the outcome of in-hospital cardiopulmonary resuscitation.
The objective of this study was to evaluate three decision-support tools (the Pre-Arrest Morbidity or PAM score, the Prognosis After Resuscitation or PAR score, and the Acute Physiology and Chronic Health Evaluation or APACHE III score) for their abilities to predict the outcomes of in-hospital cardiopulmonary resuscitation (CPR). The medical records of all 656 adult inpatients undergoing CPR during a two-to-three-year period in three large hospitals were retrospectively reviewed, and demographic and clinical variables were abstracted. Of 656 patients undergoing resuscitation, 248 (37.8%) survived the resuscitation attempt long enough to be stabilized (immediate survival), but only 35 (5.3%) survived to discharge. ⋯ This is consistent with previous work utilizing the APACHE II score, which did not identify a threshold above which patients did not benefit from CPR. The findings for the PAR score and the PAM score stand in contrast to previous studies that found them to be potentially useful decision rules. Further work is needed to develop a decision-support tool that better discriminates between survivors and non-survivors of in-hospital CPR.
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Recent studies have shown that physicians do not accurately assess patients' health status or treatment preferences. Little is known, however, about how physicians' levels of training or experience relate to their abilities to assess these preferences. To better understand this phenomenon, the authors compared the abilities of medical interns and attending physicians to predict the choices of their adult patients for end-of-life care. ⋯ For this cohort of seriously ill patients, neither medical interns nor their attending physicians were consistently accurate in assessing patients' preferences, and attending physicians were not more accurate than medical interns. Attending physicians should not assume that they can infer patients' preferences any better than the interns caring for these hospitalized patients.
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The authors examine whether Oregon's 1990, 1991, 1992, and 1993 prioritized lists were ranked in a manner consistent with cost-effectiveness. Two sets of cost-effectiveness data are used: data from economic analyses and Oregon's own cost-effectiveness data. Comparing the ranks of Oregon's lists with the ranks of cost-effectiveness estimates from the literature reveals Spearman correlations of -0.08 for the 1990 list, +0.39 for the 1991 list, +0.25 for the 1992 list, and +0.24 for the 1993 list. ⋯ In addition, there is virtually no relationship between the 1991-93 lists and Oregon's own cost-effectiveness data. Further, the correlations are very different from +1.0, suggesting that other factors are at play. For example, the 1993 list that is currently being implemented was ranked primarily by improvement in five-year survival and human judgment, not cost-effectiveness.
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Decision-making strategies used by nurses in telephone triage involving public emergency calls for medical help were investigated as a function of task urgency and complexity in the real-world dynamic environment. The sample included 34 nurses as call receivers. Transcripts of 50 nurse-client dialogues and 50 explanations of the decision-making process, elicited immediately after completion of the calls, were analyzed using methods of discourse and protocol analyses. ⋯ With the increase in problem complexity, more causal explanations were found, and the decisions were more often inaccurate. Furthermore, the explanations supporting the accurate decisions were often inaccurate, showing a decoupling of knowledge and action. Alternate strategies were used in moderate- to low-urgency conditions, where contextual knowledge of the situations was exploited to identify the needs of the clients and to negotiate the best plan of action to meet these needs, resulting in more accurate decisions.