Uncertainty in clinical decision making

PURPOSE: This study aims to conduct a comprehensive cost-effectiveness comparison between novel oral anticoagulants (NOACs) and warfarin in Chinese patients with left ventricular thrombosis (LVT). By incorporating the impact of volume-based procurement (VBP) policy for pharmaceuticals in China, this analysis intends to provide crucial insights for informed healthcare decision-making. PATIENTS AND METHODS: A Markov model was employed to simulate the disease progression of LVT over a 54-week time horizon, using weekly cycles and six mutually exclusive health states...

BACKGROUND: Knowledge of frailty is essential for meeting the Accreditation Council for Graduate Medical Education core competencies for US trainees. The UK General Medical Council requires that frailty be included in undergraduate and graduate medical education curricula. Trainees are expected to appropriately modify care plans and help make patient-centered decisions, while incorporating diagnostic uncertainty, such as frailty, in older adults. Little is known about current needs for frailty instruction in graduate medical education in the US and beyond...

The purpose of this study was to examine a nonparametric approach to mapping kinetic parameters and their uncertainties with data from the emerging generation of dynamic whole-body PET/CT scanners. Methods: Dynamic PET 18 F-FDG data from a set of 24 cancer patients studied on a long-axial-field-of-view PET/CT scanner were considered. Kinetics were mapped using a nonparametric residue mapping (NPRM) technique. Uncertainties were evaluated using an image-based bootstrapping methodology. Kinetics and bootstrap-derived uncertainties are reported for voxels, maximum-intensity projections, and volumes of interest (VOIs) corresponding to several key organs and lesions...

Persons with mental disorders have the same right to self-determination as patients with somatic diseases, also regarding death and dying. However, there are several challenges that render persons with mental disorders especially vulnerable to inappropriate conduct of assisted suicide: their wish to die may be a symptom of their mental disease and not an autonomous choice, decision-making competence may be compromised by their illness and more difficult to assess, the severity of suffering may be more difficult to evaluate from an external perspective, the wish to die may be more variable over time and the prognostic uncertainty in mental illness makes it more difficult to determine whether the severe suffering is, in fact, treatment-resistant...

Covariate analysis in population pharmacokinetics is key for adjusting doses for patients. The main objective of this work was to compare the adequacy of various modeling approaches on covariate clinical relevance decision-making. The full model, stepwise covariate model (SCM) and SCM+ PsN algorithms were compared in a clinical trial simulation of a 383-patient population pharmacokinetic study mixing rich and sparse designs. A one-compartment model with first-order absorption was used. A base model including a body weight effect on CL/F and V/F and a covariate model including 4 additional covariates-parameters relationships were simulated...

AIM: To obtain a deeper understanding of peoples' experiences of cancer treatments with immune checkpoint inhibitors (ICIs). BACKGROUND: ICIs are transforming survival outcomes for many with certain advanced cancers. Given the possibility of unique immune-related adverse events (irAEs), understanding treatment experiences is crucial to identify support needs and provide safe and effective person-centred care. DESIGN: A systematic review of qualitative research and thematic synthesis...

For older adults with serious, life-limiting illnesses near the end of life, clinicians frequently face difficult decisions about the medical care they provide because of clinical uncertainty. This difficulty is further complicated by unique challenges and medical advancements for patients with advanced heart diseases. In this article, we describe common mistakes encountered by clinicians when having goals-of-care conversations (e.g., conversations between clinicians and seriously ill patients/surrogates to discuss patient's values and goals for clinical care near the end of life...

Palliative sedation is defined as the monitored use of medications intended to induce a state of decreased or absent awareness (unconsciousness) to relieve the burden of otherwise intractable suffering in a manner ethically acceptable to the patient, their family, and healthcare providers. In Switzerland, the prevalence of continuous deep sedation until death increased from 4.7% in 2001 to 17.5% of all deceased in 2013, depending on the research method used and on regional variations. Yet, these numbers may be overestimated due to a lack of understanding of the term "continuous deep sedation" by for example respondents of the questionnaire-based study...

BACKGROUND: Emerging evidence supporting the use of valaciclovir to reduce fetal infection after maternal primary cytomegalovirus (CMV) infection has stimulated interest in routine CMV serological screening in pregnancy. It is important to understand the healthcare consumer perspective of a CMV infection during pregnancy to minimize unintended harms of screening. METHODS: We conducted a qualitative study using semi-structured interviews with Australian women who had a lived experience of CMV infection following serological testing during pregnancy...

Nationwide abortion restrictions resulting from the Dobbs v. Jackson Women's Health Organization (2022) decision have generated confusion and uncertainty among healthcare professionals, with concerns for liability impacting clinical decision-making and outcomes. The impact on pediatric surgery can be seen in prenatal counseling for fetal anomaly cases, counseling for fetal intervention, and recommendations for pregnant children and adolescents who seek termination. It is essential that all physicians and healthcare team members understand the legal implications on their clinical practices, engage with resources and organizations which can help navigate these circumstances, and consider advocating for patients and themselves...

Background: Assessing and Listening to Individual Goals and Needs (ALIGN) is a palliative care social work intervention that aims to improve delivery of goal-concordant care for hospitalized older adults with cancer discharged to skilled nursing facilities. Objective: Explore processes through which ALIGN may improve delivery of goal-concordant care to substantiate the conceptual model grounding the intervention and to inform mechanistic hypotheses of how the intervention might be effective. Design: A process evaluation triangulating findings from patient and caregiver interviews with a matrix analysis of ALIGN social worker notes...

BACKGROUND: Exercise therapy is a popular non-surgical treatment to help manage individuals with rotator cuff-related shoulder pain (RCRSP) and is recommended in all clinical practice guidelines. Due to modest effect sizes, low quality evidence, uncertainty relating to efficacy, and mechanism(s) of benefit, exercise as a therapeutic intervention has been the subject of increasing scrutiny. AIMS: The aim of this critical review is to lay out where the purported uncertainties of exercise for RCRSP exist by exploring the relevant quantitative and qualitative literature...

BACKGROUND: Resistant bacterial infections, particularly those caused by gram-negative pathogens, are associated with high mortality and economic burdens. Ceftolozane/tazobactam demonstrated efficacy comparable to meropenem in patients with ventilated hospital-acquired bacterial pneumonia in the ASPECT-NP study. One cost-effectiveness analysis in the United States revealed that ceftolozane/tazobactam was cost effective, but no Japanese studies have been conducted. Therefore, the objective of this study was to assess the cost-effectiveness of ceftolozane/tazobactam compared to meropenem for patients with ventilated hospital-acquired bacterial pneumonia/ventilator-associated bacterial pneumonia from a health care payer perspective...

PURPOSE OF REVIEW: Chronic obstructive pulmonary disease (COPD) is common in heart failure (HF), and it has a significant impact on the prognosis and quality of life of patients. Additionally, COPD is independently associated with lower adherence to first-line HF therapies. In this review, we outline the challenges of identifying and managing HF with preserved (HFpEF) and reduced (HFrEF) ejection fraction with coexisting COPD. RECENT FINDINGS: Spirometry is necessary for COPD diagnosis and prognosis but is underused in HF...

Maternal influenza immunisation (MII) is recommended for protecting pregnant women and infants under six months of age from severe disease related to influenza. However, few low-income countries have introduced this vaccine. Existing cost-effectiveness studies do not consider potential vaccine non-specific effects (NSE) observed in some settings, such as reductions in preterm birth. A decision tree model was built to examine the potential cost-effectiveness of MII in a hypothetical low-income country compared to no vaccination, considering possible values for NSE on preterm birth in addition to vaccine-specific effects on influenza...

BACKGROUND AND OBJECTIVES: Individuals with dementia may require a surrogate decision-maker as their disease progresses. To prepare for this potential role, dementia care partners need to develop a thorough understanding of their care recipient's end-of-life values and preferences, or care dyad ACP concordance. As part of our pilot study implementing the LEAD intervention with dementia care dyads, we conducted a multi-method investigation to define care dyad ACP concordance. RESEARCH DESIGN AND METHODS: We conducted a scoping review of peer-reviewed studies published after 1991 in English focusing on care dyad ACP concordance in dementia care and included 34 articles...

The impact of non-clinical factors (e.g., resident and family preferences) on prescribing is well-established. There is a gap in the literature regarding the mechanisms through which these preferences are experienced as pressure by prescribers within the unique context of residential aged-care facilities (RACFs).A significant relationship was found between nurses' anxiety, clinical tolerance of uncertainty, and the perceived need for antibiotics and assessment.As such, there is a need to expand stewardship beyond education alone to include interventions that help nurses manage uncertainty and anxiety and include other stakeholders (e...

BACKGROUND: The safety of telemedicine in general and telephone triage (teletriage) safety in particular have been a focus of concern since the 1970s. Today, telehealth, now subsuming teletriage, has a basic structure and process intended to promote safety. However, inadequate telehealth systems may also compromise patient safety. The COVID-19 pandemic accelerated rapid but uneven telehealth growth, both technologically and professionally. Within 5-10 years, the field will likely be more technologically advanced; however, these advances may still outpace professional standards...

OBJECTIVE: The significance of physician leadership to help transform the healthcare system has been increasingly discussed. This study looked at the qualities of emergency medicine (EM) physicians that support or inhibit their work as healthcare leaders. METHODS: Through an iterative process of semi-structured interviews and then focus groups, we examined why EM physicians pursue leadership roles, the strengths they bring and the frustrations they encounter. Thematic analysis identified factors that facilitate and inhibit the work of EM physicians as they enter leadership roles...

In early oncology clinical trials there is often limited data for biomarkers and their association with response to treatment. Thus, it is challenging to decide whether a biomarker should be used for patient selection and enrollment. Most evidence about any potential predictive biomarker comes from preclinical research and, sometimes, clinical observations. How to translate the preclinical predictive biomarker data to clinical study remains an active field of research. Here, we propose a method to incorporate existing knowledge about a predictive biomarker - its prevalence, association with response and the performance of the assay used to measure the biomarker - to estimate the response rate in a clinical study designed with or without using the predictive biomarker...