Although midwives make clinical decisions that have an impact on the health and well-being of mothers and babies, little is known about how they make those decisions. Wide variation in intrapartum ...decisions to refer women to obstetrician-led care suggests that midwives' decisions are based on more than the evidence based medicine (EBM) model - i.e. clinical evidence, midwife's expertise, and woman's values - alone. With this study we aimed to explore the factors that influence clinical decision-making of midwives who work independently.
We used a qualitative approach, conducting in-depth interviews with a purposive sample of 11 Dutch primary care midwives. Data collection took place between May and September 2015. The interviews were semi-structured, using written vignettes to solicit midwives' clinical decision-making processes (Think Aloud method). We performed thematic analysis on the transcripts.
We identified five themes that influenced clinical decision-making: the pregnant woman as a whole person, sources of knowledge, the midwife as a whole person, the collaboration between maternity care professionals, and the organisation of care. Regarding the midwife, her decisions were shaped not only by her experience, intuition, and personal circumstances, but also by her attitudes about physiology, woman-centredness, shared decision-making, and collaboration with other professionals. The nature of the local collaboration between maternity care professionals and locally-developed protocols dominated midwives' clinical decision-making. When midwives and obstetricians had different philosophies of care and different practice styles, their collaborative efforts were challenged.
Midwives' clinical decision-making is a more varied and complex process than the EBM framework suggests. If midwives are to succeed in their role as promoters and protectors of physiological pregnancy and birth, they need to understand how clinical decisions in a multidisciplinary context are actually made.
Drug discovery and development pipelines are long, complex and depend on numerous factors. Machine learning (ML) approaches provide a set of tools that can improve discovery and decision making for ...well-specified questions with abundant, high-quality data. Opportunities to apply ML occur in all stages of drug discovery. Examples include target validation, identification of prognostic biomarkers and analysis of digital pathology data in clinical trials. Applications have ranged in context and methodology, with some approaches yielding accurate predictions and insights. The challenges of applying ML lie primarily with the lack of interpretability and repeatability of ML-generated results, which may limit their application. In all areas, systematic and comprehensive high-dimensional data still need to be generated. With ongoing efforts to tackle these issues, as well as increasing awareness of the factors needed to validate ML approaches, the application of ML can promote data-driven decision making and has the potential to speed up the process and reduce failure rates in drug discovery and development.
The posterior parietal cortex (PPC) has an important role in many cognitive behaviours; however, the neural circuit dynamics underlying PPC function are not well understood. Here we optically imaged ...the spatial and temporal activity patterns of neuronal populations in mice performing a PPC-dependent task that combined a perceptual decision and memory-guided navigation in a virtual environment. Individual neurons had transient activation staggered relative to one another in time, forming a sequence of neuronal activation spanning the entire length of a task trial. Distinct sequences of neurons were triggered on trials with opposite behavioural choices and defined divergent, choice-specific trajectories through a state space of neuronal population activity. Cells participating in the different sequences and at distinct time points in the task were anatomically intermixed over microcircuit length scales (<100 micrometres). During working memory decision tasks, the PPC may therefore perform computations through sequence-based circuit dynamics, rather than long-lived stable states, implemented using anatomically intermingled microcircuits.
Shared decision making (SDM)-when clinicians and patients make medical decisions together-is moving swiftly from an ethical ideal toward widespread clinical implementation affecting millions of ...patients through recent policy initiatives. We argue that policy initiatives to promote SDM implementation in clinical practice carry the risk of several unintended negative consequences if limitations in defining and measuring SDM are not addressed. We urge policy makers to include prespecified definitions of desired outcomes, offer guidance on the tools used to measure SDM in the multitude of contexts in which it occurs, evaluate the impact of SDM policy initiatives over time, review that impact at regular intervals, and revise SDM measurement tools as needed.
Objective. The IPDAS Collaboration has developed a checklist and an instrument (IPDASi v3.0) to assess the quality of patient decision aids (PDAs) in terms of their development process and shared ...decision-making design components. Certification of PDAs is of growing interest in the US and elsewhere. We report a modified Delphi consensus process to agree on IPDASi (v3.0) items that should be considered as minimum standards for PDA certification, for inclusion in the refined IPDASi (v4.0). Methods. A 2-stage Delphi voting process considered the inclusion of IPDASi (v3.0) items as minimum standards. Item scores and qualitative comments were analyzed, followed by expert group discussion. Results. One hundred and one people voted in round 1; 87 in round 2. Forty-seven items were reduced to 44 items across 3 new categories: 1) qualifying criteria, which are required in order for an intervention to be considered a decision aid (6 items); 2) certification criteria, without which a decision aid is judged to have a high risk of harmful bias (10 items); and 3) quality criteria, believed to strengthen a decision aid but whose omission does not present a high risk of harmful bias (28 items). Conclusions. This study provides preliminary certification criteria for PDAs. Scoring and rating processes need to be tested and finalized. However, the process of appraising the quality of the clinical evidence reported by the PDA should be used to complement these criteria; the proposed standards are designed to rate the quality of the development process and shared decision-making design elements, not the quality of the PDA’s clinical content.
Background/objectives
Restricted mean survival time (RMST) summarizes treatment effect in terms of a gain or loss in the event‐free days. It remains uncertain whether communicating treatment benefit ...and harm using RMST‐based summary is more effective than conventional summary based on absolute and relative risk reduction. We compared the effect of RMST‐based approach and conventional approach on decisional conflict using an example of intensive versus standard blood pressure‐lowering strategies.
Design
On‐line survey.
Setting
A convenience sample of patients in the United States.
Participants
Two hundred adults aged 65 and older with hypertension requiring anti‐hypertensive treatment (response rate 85.5%).
Interventions
Participants were randomly assigned to either RMST‐based summary or conventional summary about the benefit and harm of blood pressure‐lowering strategies.
Measurements
Decisional Conflict Scale (DCS), ranging from 0 (no conflict) to 100 (high conflict), and preference for intensive blood pressure‐lowering strategy.
Results
Participants assigned to RMST‐based approach (n = 100) and conventional approach (n = 100) had similar age (mean standard deviation, SD: 72.3 5.6 vs 72.8 5.5 years) and proportions of female (50 50.0% vs 61 61.0%) and white race (92 92.0% vs 92 92.0%). The mean (SD) DCS score was 25.2 (15.0) for RMST‐based approach and 25.6 (14.1) for conventional approach (p = 0.84). The number (%) of participants who preferred intensive strategy was 10 (10.0%) for RMST‐based approach and 14 (14.0%) for conventional approach (p = 0.52). The results were consistent in subgroups defined by age, sex, education level, cardiovascular disease status, and predicted mortality risk categories.
Conclusion
In a sample of relatively healthy older adults with hypertension, RMST‐based approach was as effective as conventional approach on decisional conflict about choosing a blood pressure‐lowering strategy. This study provides proof‐of‐concept evidence that RMST‐based approach can be used in conjunction with absolute and relative risk reduction for communicating treatment benefit and harm in a decision aid.
Evaluation based on distance from average solution (EDAS), developed in 2015, is one of the well-known and frequently utilized methods which is applied for different types of decision making ...problems. The output of EDAS is a ranking order of alternatives based on their aggregated distance scores. In this regard, the literature lacks a comprehensive literature review on the developments and applications of EDAS. For this purpose, this study conducts a comprehensive literature review on developments, extensions, and applications of the EDAS method. First, the EDAS method and its well-known extensions are shortly introduced. Next, a theoretical literature review of studies is presented. A meta analysis is performed in terms of publication year, authors, authors’ countries, journals, and combined methods, uncertainty sets. Practical problems of the EDAS are categorized into nine application groups as agriculture, business management, construction management, energy and natural resources, healthcare management, information technology (IT), manufacturing, supply chain management, and transportation management. Results of this study can empower real-life decision makers to handle vague and incomplete information involved in decision process, and express opinions of different stakeholders in different applications under novel extensions of the EDAS.
•A state-of the-art literature review on EDAS and its fuzzy extensions are provided.•It presents an insight for researchers and practitioners on EDAS applications.•Highlight the recent developments of the EDAS under different uncertain environments.•Recommendations lists of develop the EDAS and its extension in the literature.
Management of patients with temporomandibular disorders (TMD) appears to be more challenging than for other dental conditions. This study aimed to explore the decision‐making process in TMD ...management, and thereby to conceptualize the decision‐making process in dentistry. Individual semi‐structured interviews were conducted during 2018 and 2019 with a purposive sample of 22 general dental practitioners from the Public Dental Healthcare Services and private practices in the Region of Västerbotten, Northern Sweden. The interviews were analysed using the Grounded Theory approach of Charmaz. Data analysis resulted in the core category ‘Combining own competence and others’ expectations in the desire to do the right thing’. The dentists showed interest in and a desire to apply professional knowledge, but also reflected on challenges and complexity in the decision‐making process for TMD. The challenges were primarily related to organisational factors and lack of self‐confidence. This identifies a need for re‐organisation of daily clinical management in dentistry, and a need for more postgraduate training to improve self‐confidence. The complexity of the decision‐making process for TMD makes the study findings applicable in other dental situations.
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