Innovations in applied decision theory for health and safety.

OBJECTIVES: There are established methods for occupational epidemiological cohort analysis, such as proportional hazards regression, that are well suited to aetiological research and yield parameter estimates that allow for succinct communication among academics. However, these methods are not necessarily well suited for evaluation of health impacts of policy choices and communication to decision makers. An informed decision about a policy that impacts health and safety requires a valid estimate of the policy's potential impact. METHODS: We propose methods for data summarisation that may facilitate communication with managers, workers and their advocates. We calculate measures of effect in a framework for competing events, graphically display potential impacts on cause-specific mortality under policy alternatives and contrast these results to estimates obtained using standard Poisson regression methods. Methods are illustrated using a cohort mortality study of 28 546 Ontario uranium miners hired between 1950 and 1996 and followed through 2007. RESULTS: A standard regression analysis yields a positive association between cumulative radon progeny exposure and all-cause mortality (log(RR per 100 WLM)=0.09; SE=0.02). The proposed method yields an estimate of the expected gain in life expectancy (approximately 6 months per worker) and reduction of 261 lung cancer deaths under a policy that eliminated occupational radon progeny exposure. CONCLUSIONS: The proposed method shifts attention from covariate-adjusted risk ratios or rate ratios to estimates of deaths that are avoided or delayed under a potential policy. The approach may help inform decision-making and strengthen the connection of epidemiological approaches to data analysis with developments in decision theory and systems engineering to improve health and safety.

Subgroup finding via Bayesian additive regression trees.

We provide a Bayesian decision theoretic approach to finding subgroups that have elevated treatment effects. Our approach separates the modeling of the response variable from the task of subgroup finding and allows a flexible modeling of the response variable irrespective of potential subgroups of interest. We use Bayesian additive regression trees to model the response variable and use a utility function defined in terms of a candidate subgroup and the predicted response for that subgroup. Subgroups are identified by maximizing the expected utility where the expectation is taken with respect to the posterior predictive distribution of the response, and the maximization is carried out over an a priori specified set of candidate subgroups. Our approach allows subgroups based on both quantitative and categorical covariates. We illustrate the approach using simulated data set study and a real data set. Copyright © 2017 John Wiley & Sons, Ltd.

Reasoning and action: implementation of a decision-making program in sport

The objective of this study was to apply a decision training programme, based on the use of video-feedback and questioning, in real game time, in order to improve decision-making in volleyball attack actions. A three-phase quasi-experimental design was implemented: Phase A (pre-test), Phase B (Intervention) and Phase C (Retention). The sample was made up of 8 female Under-16 volleyball players, who were divided into two groups: experimental group (n = 4) and control group (n = 4). The independent variable was the decision training program, which was applied for 11 weeks in a training context, more specifically in a 6x6 game situation. The player had to analyze the reasons and causes of the decision taken. The dependent variable was decision-making, which was assessed based on systematic observation, using the «Game Performance Assessment Instrument» (GPAI) (Oslin, Mitchell, & Griffin, 1998). Results showed that, after applying the decision training program, the experimental group showed a significantly higher average percentage of successful decisions than the control group F(1, 6) = 11.26; p = .015; η2 p = .652; 95% CI [056, 360]. These results highlight the need to complement the training process with cognitive tools such as video-feedback and questioning in order to improve athletes’ decision-making (AU)

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Anterior temporal lobectomy compared with laser thermal hippocampectomy for mesial temporal epilepsy: A threshold analysis study.

PURPOSE: Anterior Temporal Lobectomy (ATL) is the gold standard surgical treatment for refractory temporal lobe epilepsy (TLE), but it carries the risks associated with invasiveness, including cognitive and visual deficits and potential damage to eloquent structures. Laser thermal hippocampectomy (LTH) is a new procedure that offers a less invasive alternative to the standard open approach. In this decision analysis, we determine the seizure freedom rate at which LTH would be equivalent to ATL. METHODS: MEDLINE searches were performed for studies of ATL from 1995 to 2014. Using complication and success rates from the literature, we constructed a decision analysis model for treatment with ATL and LTH. Quality-adjusted life years (QALYs) were derived from examining patient preferences in similar clinical conditions. LTH data were obtained from a preliminary multicenter study report following patients for 6-12 months. A sensitivity analysis in which major parameters were systematically varied within their 95% CIs was used. RESULTS: 350 studies involving 25,144 cases of ATL were included. Outcomes of LTH were taken from a recently presented multicenter series of 68 cases. Over a 10-year postoperative modeling period, LTH value was 5.9668 QALYs and ATL value was 5.8854. Sensitivity analysis revealed that probabilities of seizure control and late morbidity of LTH are most likely to affect outcomes compared to ATL. We calculated that LTH would need to stop disabling seizures (Engel class I) in at least 43% of cases and have fewer than 40% late mortality/morbidity to result in quality of life at least as good as that after ATL. CONCLUSIONS: This decision analysis based on early follow-up data suggests LTH has similar utility to ATL. These early data support LTH as a potentially comparable less invasive alternative to ATL in refractory TLE. LTH utility may remain comparable to ATL even if long-term seizure control is less than that of ATL. Larger prospective studies with long-term follow up will be needed to validate the true role of LTH in the refractory epilepsy patient population.

Factors involved in the collaboration between the national comprehensive cancer control programs and tobacco control programs: a qualitative study of 6 States, United States, 2012.

INTRODUCTION: Historically, federal funding streams to address cancer and tobacco use have been provided separately to state health departments. This study aims to document the impact of a recent focus on coordinating chronic disease efforts through collaboration between the 2 programs. METHODS: Through a case-study approach using semistructured interviews, we collected information on the organizational context, infrastructure, and interaction between cancer and tobacco control programs in 6 states from March through July 2012. Data were analyzed with NVivo software, using a grounded-theory approach. RESULTS: We found between-program activities in the state health department and coordinated implementation of interventions in the community. Factors identified as facilitating integrated interventions in the community included collaboration between programs in the strategic planning process, incorporation of one another's priorities into state strategic plans, co-location, and leadership support for collaboration. Coalitions were used to deliver integrated interventions to the community. Five states perceived high staff turnover as a barrier to collaboration, and all 5 states felt that federal funding requirements were a barrier. CONCLUSIONS: Cancer and tobacco programs are beginning to implement integrated interventions to address chronic disease. Findings can inform the development of future efforts to integrate program activities across chronic disease prevention efforts.

O Iowa Gambling Task: uma revisão crítica / The Iowa Gambling Task: a critical revision

O Iowa Gambling Task (IGT) é uma tarefa amplamente utilizada na avaliação da capacidade de tomada de decisão. Neste artigo, procede-se à revisão da literatura, comparando-se as versões do IGT, as diferentes medidas de avaliação do desempenho e as alterações introduzidas nos procedimentos, nomeadamente no feedback, na aleatorização espacial dos baralhos, no número de ensaios e de cartas por baralho, nas instruções, na remuneração e na manipulação das recompensas e punições. Desta análise, conclui-se que as diversas versões da tarefa, as alterações nos procedimentos de aplicação e as diferentes medidas utilizadas na avaliação têm impacto no desempenho, prejudicam a comparação entre estudos e as generalizações dos resultados. Finalmente, apresentam-se sugestões para uma maior adequação dos procedimentos.(AU)

The Iowa Gambling Task (IGT) is a widely used task in the assessment of the decision-making ability. In this article, we conduct a literature review by comparing IGT versions, different performance assessment measures, and changes to procedures including feedback, spatial randomization of decks, number of trials, number of cards per deck, instructions, payment, and rewards and punishments. On basis of this analysis, we conclude that different versions of the task, changes in application procedures and different measures used to assess the task have an impact on performance, thereby affecting comparison among studies and generalization of results. Finally, we offer suggestions to define adequate procedures.(AU)

Comparative effectiveness research on patients with acute ischemic stroke using Markov decision processes.

BACKGROUND: Several methodological issues with non-randomized comparative clinical studies have been raised, one of which is whether the methods used can adequately identify uncertainties that evolve dynamically with time in real-world systems. The objective of this study is to compare the effectiveness of different combinations of Traditional Chinese Medicine (TCM) treatments and combinations of TCM and Western medicine interventions in patients with acute ischemic stroke (AIS) by using Markov decision process (MDP) theory. MDP theory appears to be a promising new method for use in comparative effectiveness research. METHODS: The electronic health records (EHR) of patients with AIS hospitalized at the 2nd Affiliated Hospital of Guangzhou University of Chinese Medicine between May 2005 and July 2008 were collected. Each record was portioned into two "state-action-reward" stages divided by three time points: the first, third, and last day of hospital stay. We used the well-developed optimality technique in MDP theory with the finite horizon criterion to make the dynamic comparison of different treatment combinations. RESULTS: A total of 1504 records with a primary diagnosis of AIS were identified. Only states with more than 10 (including 10) patients' information were included, which gave 960 records to be enrolled in the MDP model. Optimal combinations were obtained for 30 types of patient condition. CONCLUSION: MDP theory makes it possible to dynamically compare the effectiveness of different combinations of treatments. However, the optimal interventions obtained by the MDP theory here require further validation in clinical practice. Further exploratory studies with MDP theory in other areas in which complex interventions are common would be worthwhile.

Evaluation of remedial options for a benzene-contaminated site through a simulation-based fuzzy-MCDA approach.

A simulation-based fuzzy multi-criteria decision analysis (SFMCDA) method is developed for supporting the selection of remediation strategies for petroleum contaminated sites. SFMCDA integrates process modeling (using BIOPLUME III) and fuzzy ranking (based on fuzzy TOPSIS) into a general management framework, and can compare various remediation alternatives, in light of both cost-risk tradeoffs and uncertainty impacts. The proposed method is applied to a hypothetical contaminated site suffering from a benzene leakage problem. Six remediation alternatives are taken into consideration, including natural attenuation (NA), pump-and-treat (PAT), enhanced natural attenuation (ENA), and a number of their combinations. Six fuzzy criteria, including both cost and risk information, are used to compare different alternatives through fuzzy TOPSIS. The results demonstrates that the proposed method can help systematically analyze fuzzy inputs from contaminant transport modeling, cost implications and stakeholders' preferences, and provide useful ranking information covering a variety of decision-relevant remediation options for decision makers.

Recalibration of the auditory continuity illusion: sensory and decisional effects.

An interrupted sound can be perceived as continuous when noise masks the interruption, creating an illusion of continuity. Recent findings have shown that adaptor sounds preceding an ambiguous target sound can influence listeners' rating of target continuity. However, it remains unclear whether these aftereffects on perceived continuity influence sensory processes, decisional processes (i.e., criterion shifts), or both. The present study addressed this question. Results show that the target sound was more likely to be rated as 'continuous' when preceded by adaptors that were perceived as clearly discontinuous than when it was preceded by adaptors that were heard (illusorily or veridically) as continuous. Detection-theory analyses indicated that these contrastive aftereffects reflect a combination of sensory and decisional processes. The contrastive sensory aftereffect persisted even when adaptors and targets were presented to opposite ears, suggesting a neural origin in structures that receive binaural inputs. Finally, physically identical but perceptually ambiguous adaptors that were rated as 'continuous' induced more reports of target continuity than adaptors that were rated as 'discontinuous'. This assimilative aftereffect was purely decisional. These findings confirm that judgments of auditory continuity can be influenced by preceding events, and reveal that these aftereffects have both sensory and decisional components.

Actor-Network Theory and its role in understanding the implementation of information technology developments in healthcare.

BACKGROUND: Actor-Network Theory (ANT) is an increasingly influential, but still deeply contested, approach to understand humans and their interactions with inanimate objects. We argue that health services research, and in particular evaluations of complex IT systems in health service organisations, may benefit from being informed by Actor-Network Theory perspectives. DISCUSSION: Despite some limitations, an Actor-Network Theory-based approach is conceptually useful in helping to appreciate the complexity of reality (including the complexity of organisations) and the active role of technology in this context. This can prove helpful in understanding how social effects are generated as a result of associations between different actors in a network. Of central importance in this respect is that Actor-Network Theory provides a lens through which to view the role of technology in shaping social processes. Attention to this shaping role can contribute to a more holistic appreciation of the complexity of technology introduction in healthcare settings. It can also prove practically useful in providing a theoretically informed approach to sampling (by drawing on informants that are related to the technology in question) and analysis (by providing a conceptual tool and vocabulary that can form the basis for interpretations). We draw on existing empirical work in this area and our ongoing work investigating the integration of electronic health record systems introduced as part of England's National Programme for Information Technology to illustrate salient points. SUMMARY: Actor-Network Theory needs to be used pragmatically with an appreciation of its shortcomings. Our experiences suggest it can be helpful in investigating technology implementations in healthcare settings.

Amatoxin poisoning treatment decision-making: pharmaco-therapeutic clinical strategy assessment using multidimensional multivariate statistic analysis.

Ninety percent of fatal higher fungus poisoning is due to amatoxin-containing mushroom species. In addition to absence of antidote, no chemotherapeutic consensus was reported. The aim of the present study is to perform a retrospective multidimensional multivariate statistic analysis of 2110 amatoxin poisoning clinical cases, in order to optimize therapeutic decision-making. Our results allowed to classify drugs as a function of their influence on one major parameter: patient survival. Active principles were classified as first intention, second intention, adjuvant or controversial pharmaco-therapeutic clinical intervention. We conclude that (1) retrospective multidimensional multivariate statistic analysis of complex clinical dataset might help future therapeutic decision-making and (2) drugs such as silybin, N-acetylcystein and putatively ceftazidime are clearly associated, in amatoxin poisoning context, with higher level of patient survival.

Rational choice, neuroeconomy and mixed emotions.

Experimental psychology has shown differences between predictions of theory of decision and human choices. Emotions like regret can partly explain these differences. Neuroimagery used in combination with behavioural economics (neuroeconomics) has been used in order to try to disentangle the different emotional and rational factors (regret, rejoicing, reward, costs, uncertainty, trade-off between positive and negative aspects of different options). Emotions then appear as much more complex and mixed affective states than usually assumed. Not only might we feel a positive affect in punishing unfair partners, but mixed emotions can, for example, combine transmutation of previous anxiety into relief and elation by comparison with another less exciting option (elating relief). At the level of complexity of these mixed emotions--which we formally represent by comparisons between 'unexpected utilities' and expected ones--the main biases that Kahnemann and Tversky have shown can be explained. In spite of the complexity of these mixed emotions, some of these hypotheses might be partially tested by brain imagery.

A theory of utility conditionals: Paralogical reasoning from decision-theoretic leakage.

Many "if p, then q" conditionals have decision-theoretic features, such as antecedents or consequents that relate to the utility functions of various agents. These decision-theoretic features leak into reasoning processes, resulting in various paralogical conclusions. The theory of utility conditionals offers a unified account of the various forms that this phenomenon can take. The theory is built on 2 main components: (1) a representational tool (the utility grid), which summarizes in compact form the decision-theoretic features of a conditional, and (2) a set of folk axioms of decision, which reflect reasoners' beliefs about the way most agents make their decisions. Applying the folk axioms to the utility grid of a conditional allows for the systematic prediction of the paralogical conclusions invited by the utility grid's decision-theoretic features. The theory of utility conditionals significantly extends the scope of current theories of conditional inference and moves reasoning research toward a greater integration with decision-making research.

Differential analysis for high density tiling microarray data.

BACKGROUND: High density oligonucleotide tiling arrays are an effective and powerful platform for conducting unbiased genome-wide studies. The ab initio probe selection method employed in tiling arrays is unbiased, and thus ensures consistent sampling across coding and non-coding regions of the genome. These arrays are being increasingly used to study the associated processes of transcription, transcription factor binding, chromatin structure and their association. Studies of differential expression and/or regulation provide critical insight into the mechanics of transcription and regulation that occurs during the developmental program of a cell. The time-course experiment, which comprises an in-vivo system and the proposed analyses, is used to determine if annotated and un-annotated portions of genome manifest coordinated differential response to the induced developmental program. RESULTS: We have proposed a novel approach, based on a piece-wise function - to analyze genome-wide differential response. This enables segmentation of the response based on protein-coding and non-coding regions; for genes the methodology also partitions differential response with a 5' versus 3' versus intra-genic bias. CONCLUSION: The algorithm built upon the framework of Significance Analysis of Microarrays, uses a generalized logic to define regions/patterns of coordinated differential change. By not adhering to the gene-centric paradigm, discordant differential expression patterns between exons and introns have been identified at a FDR of less than 12 percent. A co-localization of differential binding between RNA Polymerase II and tetra-acetylated histone has been quantified at a p-value < 0.003; it is most significant at the 5' end of genes, at a p-value < 10-13. The prototype R code has been made available as supplementary material [see Additional file 1].

Influence of data display formats on physician investigators' decisions to stop clinical trials: prospective trial with repeated measures.

OBJECTIVE: To examine the effect of the method of data display on physician investigators' decisions to stop hypothetical clinical trials for an unplanned statistical analysis. DESIGN: Prospective, mixed model design with variables between subjects and within subjects (repeated measures). SETTING: Comprehensive cancer centre. PARTICIPANTS: 34 physicians, stratified by academic rank, who were conducting clinical trials. INTERVENTIONS: PARTICIPANTS were shown tables, pie charts, bar graphs, and icon displays containing hypothetical data from a clinical trial and were asked to decide whether to continue the trial or stop for an unplanned statistical analysis. MAIN OUTCOME MEASURE: Percentage of accurate decisions with each type of display. RESULTS: Accuracy of decisions was affected by the type of data display and positive or negative framing of the data. More correct decisions were made with icon displays than with tables, pie charts, and bar graphs (82% v 68%, 56%, and 43%, respectively; P=0.03) and when data were negatively framed rather than positively framed in tables (93% v 47%; P=0.004). CONCLUSIONS: Clinical investigators' decisions can be affected by factors unrelated to the actual data. In the design of clinical trials information systems, careful consideration should be given to the method by which data are framed and displayed in order to reduce the impact of these extraneous factors.

Decision-making theory and HIV disease.

AIDS: AIDS treatment is sophisticated and complex, requiring difficult decisions about when to begin treatment, how aggressively to treat the infection, and which alternative therapies to pursue. Health care professionals need to be able to calculate risks and to help patients weigh their treatment options. Ideally, clinicians should present all options and discuss why they advocate some and not others. Unconventional treatments should also receive attention, because a patient may lend more credibility to options he or she believes is being purposefully concealed. Treatment decisions can be turned into a formula by estimating the good or bad value of each possible outcome of an action, multiplying that figure by the outcome's probability, and adding up the products from all the outcomes. Even if the person does not wish to base a decision on the formula, they have at least given careful consideration to all the issues. Creating a record of the decision-making process can also help ease regret caused by hindsight or outcome bias.^ieng

Alternative therapies as control behaviours used by cancer patients.

Alternative health care practices are a way in which cancer patients can be in control of their illness situation. This assumption is investigated through control theory. While the sociocultural schemas of North American patients endorse control of illness, the stress of the cancer experience dismisses the advantage of control behaviours. Analysis also suggests that patients find ways to escape from the freedom of being in control of their health situation. This post-analysis of a recent study uncovers major ambiguities concerning the control behaviours of cancer patients.

Decision rules in detection of simple and complex tones.

Detection of simple and complex tones in the presence of a 64-dB SPL uniformly masking noise was examined in two experiments. In both experiments, the signals were either pure tones (220, 1100, or 3850 Hz) or an 18-tone complex consisting of equally intense components between 110 and 7260 Hz. In experiment 1, psychometric functions were obtained for detection in a 2I, 2AFC task. Results for eight normal listeners show that the psychometric functions are parallel for simple and complex tones. As expected, the masked thresholds for the pure tones are 43-44 dB SPL independent of frequency; the masked threshold for the complex tone is about 37 dB SPL per tone. These results indicate that the simultaneous presence of signal energy in many auditory channels aids detection. In experiment 2, psychometric functions were obtained with all four signals presented in random order within a block of trials. Results for four normal listeners show that the psychometric functions are parallel to one another and to those obtained in experiment 1. The thresholds are elevated to about 46 dB for the pure tones and to 40.5 dB for the complex tone. These results are nearly, but not quite, consistent with a multiband energy-detector model using an optimum decision rule; it appears that listeners may only make an unweighted sum of decision variables across an optimum selection of channels.