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1.
Stud Health Technol Inform ; 273: 217-222, 2020 Sep 04.
Artículo en Inglés | MEDLINE | ID: mdl-33087615

RESUMEN

The questions 'What constitutes a good health care decision?', and, by extension, 'What constitutes good healthcare decision support?' continue to be asked. The most developed answers focus largely, often exclusively, on the quality of the 'deliberation' component as the determinant of the quality of the decision or decision aid. We argue that these answers and resulting aids reflect the preferences of healthcare professionals and aid developers and that these preferences are closely aligned with their interests. Some interests are material, but many professional, institutional, intellectual, methodological, and ethical. Successful promotion of a particular preference-sensitive, interest-conflicted decision aid does not change its ontological nature. Conflicts of interest are therefore universal and of concern only when this ontology is denied and if aids based on alternative interest-based preferences, such as technologies involving numerical analytic calculation, are subjected to discrimination.


Asunto(s)
Conflicto de Intereses , Técnicas de Apoyo para la Decisión , Prestación de Atención de Salud
2.
JAMA ; 324(14): 1406-1418, 2020 10 13.
Artículo en Inglés | MEDLINE | ID: mdl-33048154

RESUMEN

Importance: Persistent smoking may cause adverse outcomes among patients with cancer. Many cancer centers have not fully implemented evidence-based tobacco treatment into routine care. Objective: To determine the effectiveness of sustained telephone counseling and medication (intensive treatment) compared with shorter-term telephone counseling and medication advice (standard treatment) to assist patients recently diagnosed with cancer to quit smoking. Design, Setting, and Participants: This unblinded randomized clinical trial was conducted at Massachusetts General Hospital/Dana-Farber/Harvard Cancer Center and Memorial Sloan Kettering Cancer Center. Adults who had smoked 1 cigarette or more within 30 days, spoke English or Spanish, and had recently diagnosed breast, gastrointestinal, genitourinary, gynecological, head and neck, lung, lymphoma, or melanoma cancers were eligible. Enrollment occurred between November 2013 and July 2017; assessments were completed by the end of February 2018. Interventions: Participants randomized to the intensive treatment (n = 153) and the standard treatment (n = 150) received 4 weekly telephone counseling sessions and medication advice. The intensive treatment group also received 4 biweekly and 3 monthly telephone counseling sessions and choice of Food and Drug Administration-approved cessation medication (nicotine replacement therapy, bupropion, or varenicline). Main Outcome and Measures: The primary outcome was biochemically confirmed 7-day point prevalence tobacco abstinence at 6-month follow-up. Secondary outcomes were treatment utilization rates. Results: Among 303 patients who were randomized (mean age, 58.3 years; 170 women [56.1%]), 221 (78.1%) completed the trial. Six-month biochemically confirmed quit rates were 34.5% (n = 51 in the intensive treatment group) vs 21.5% (n = 29 in the standard treatment group) (difference, 13.0% [95% CI, 3.0%-23.3%]; odds ratio, 1.92 [95% CI, 1.13-3.27]; P < .02). The median number of counseling sessions completed was 8 (interquartile range, 4-11) in the intensive treatment group. A total of 97 intensive treatment participants (77.0%) vs 68 standard treatment participants (59.1%) reported cessation medication use (difference, 17.9% [95% CI, 6.3%-29.5%]; odds ratio, 2.31 [95% CI, 1.32-4.04]; P = .003). The most common adverse events in the intensive treatment and standard treatment groups, respectively, were nausea (n = 13 and n = 6), rash (n = 4 and n = 1), hiccups (n = 4 and n = 1), mouth irritation (n = 4 and n = 0), difficulty sleeping (n = 3 and n = 2), and vivid dreams (n = 3 and n = 2). Conclusions and Relevance: Among smokers recently diagnosed with cancer in 2 National Cancer Institute-designated Comprehensive Cancer Centers, sustained counseling and provision of free cessation medication compared with 4-week counseling and medication advice resulted in higher 6-month biochemically confirmed quit rates. However, the generalizability of the study findings is uncertain and requires further research. Trial Registration: ClinicalTrials.gov Identifier: NCT01871506.


Asunto(s)
Consejo/métodos , Neoplasias/diagnóstico , Cese del Hábito de Fumar/psicología , Templanza/psicología , Dispositivos para Dejar de Fumar Tabaco , Anciano , Bupropión/efectos adversos , Bupropión/uso terapéutico , Cotinina/análisis , Consejo/estadística & datos numéricos , Técnicas de Apoyo para la Decisión , Femenino , Humanos , Masculino , Persona de Mediana Edad , Entrevista Motivacional , Satisfacción del Paciente , Selección de Paciente , Saliva/química , Fumar/tratamiento farmacológico , Fumar/epidemiología , Fumar/psicología , Agentes para el Cese del Hábito de Fumar/efectos adversos , Agentes para el Cese del Hábito de Fumar/uso terapéutico , Teléfono , Dispositivos para Dejar de Fumar Tabaco/efectos adversos , Vareniclina/efectos adversos , Vareniclina/uso terapéutico
3.
Environ Monit Assess ; 192(11): 682, 2020 Oct 07.
Artículo en Inglés | MEDLINE | ID: mdl-33030635

RESUMEN

Sanitary waste disposal and site selection for establishing landfills are challenging problems for environmental planners. This paper aims to take environmental, socio-economic, geological, geomorphological, hydrological and ecological factors into consideration to provide a decision support framework for landfill siting. Analytical hierarchy process (AHP) and Decision Making Trial and Evaluation Laboratory (DEMATEL) are coupled to develop an efficient multi-criteria decision-making method to be utilized in a Geographic Information System (GIS) environment for evaluating the suitability for landfill siting. As the first attempt to employ DEMATEL effectively in a landfill site selection problem, the proposed method is tested with landfill siting scenarios in New South Wales (NSW), Australia. Regional analysis is also performed to identify the potentially most suitable statistical divisions for landfill siting in NSW. The top two ranked zones covering 0.7% and 22% of the study area, respectively, are considered as the optimal areas for establishing landfills, while the bottom two ranked zones are not recommended for further consideration. Further detailed analysis is also conducted on the existing landfills, which shows that 1.0% and 37.0% of them are ranks 1 and 2, respectively. The scenario-based analysis implies that, among the contributing factors; geological and economic factors are highly important.


Asunto(s)
Técnicas de Apoyo para la Decisión , Residuos Sólidos , Australia , Monitoreo del Ambiente , Nueva Gales del Sur , Instalaciones de Eliminación de Residuos
4.
Artículo en Inglés | MEDLINE | ID: mdl-33114587

RESUMEN

Aim: In this article, we aim to present a tool for the early assessment of medical technologies. This evaluation system was designed and implemented by the National Centre for HTA and the National Centre for Innovative Technologies of the Istituto Superiore di Sanita, Italy, in order to respond to an institutional commitment within the "Health Technologies Assessment Team" that was established to face the huge demand for the evaluation of Health Technologies during the pandemic event caused by COVID-19, with a smart and easy-to-use framework. Methods: Horizon scanning was conducted through a brief assessment carried out according to the multicriteria decision analysis methodology. Each HTA domain was attributed a score according to a pros/cons and opportunities/threats system, derived from evidence in the literature. Scores were weighted according to different perspectives. Scores were presented in a Cartesian graph showing the positioning according to the potential value and the perceived risk associated with the technology. Results: Two case studies regarding the early assessment were reported, concerning two specific technologies: an individual protection device and a contact tracking system.


Asunto(s)
Infecciones por Coronavirus , Técnicas de Apoyo para la Decisión , Pandemias , Neumonía Viral , Evaluación de la Tecnología Biomédica , Betacoronavirus , Humanos , Italia , Riesgo
5.
Comput Math Methods Med ; 2020: 9391251, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-32908584

RESUMEN

In this paper, a utility-based multicriteria model is proposed to support the physicians to deal with an important medical decision-the screening decision problem-given the squeeze put on resources due to the COVID-19 pandemic. Since the COVID-19 emerged, the number of patients with an acute respiratory failure has increased in the health units. This chaotic situation has led to a deficiency in health resources. Thus, this study, using the concepts of the multiattribute utility theory (MAUT), puts forward a mathematical model to aid physicians in the screening decision problem. The model is used to generate which of the three alternatives is the best one for where patients with suspected COVID-19 should be treated, namely, an intensive care unit (ICU), a hospital ward, or at home in isolation. Also, a decision information system, called SIDTriagem, is constructed and illustrated to operate the mathematical model proposed.


Asunto(s)
Betacoronavirus , Técnicas de Laboratorio Clínico/estadística & datos numéricos , Infecciones por Coronavirus/diagnóstico , Pandemias , Neumonía Viral/diagnóstico , Infecciones por Coronavirus/epidemiología , Infecciones por Coronavirus/terapia , Cuidados Críticos , Toma de Decisiones Asistida por Computador , Técnicas de Apoyo para la Decisión , Servicios de Atención de Salud a Domicilio , Hospitalización , Humanos , Tamizaje Masivo , Conceptos Matemáticos , Método de Montecarlo , Aislamiento de Pacientes , Neumonía Viral/epidemiología , Neumonía Viral/terapia , Triaje/métodos
7.
J Stroke Cerebrovasc Dis ; 29(10): 105162, 2020 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-32912543

RESUMEN

Machine Learning (ML) delivers an accurate and quick prediction outcome and it has become a powerful tool in health settings, offering personalized clinical care for stroke patients. An application of ML and Deep Learning in health care is growing however, some research areas do not catch enough attention for scientific investigation though there is real need of research. Therefore, the aim of this work is to classify state-of-arts on ML techniques for brain stroke into 4 categories based on their functionalities or similarity, and then review studies of each category systematically. A total of 39 studies were identified from the results of ScienceDirect web scientific database on ML for brain stroke from the year 2007 to 2019. Support Vector Machine (SVM) is obtained as optimal models in 10 studies for stroke problems. Besides, maximum studies are found in stroke diagnosis although number for stroke treatment is least thus, it identifies a research gap for further investigation. Similarly, CT images are a frequently used dataset in stroke. Finally SVM and Random Forests are efficient techniques used under each category. The present study showcases the contribution of various ML approaches applied to brain stroke.


Asunto(s)
Encéfalo/fisiopatología , Técnicas de Apoyo para la Decisión , Diagnóstico por Computador , Aprendizaje Automático , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/terapia , Terapia Asistida por Computador , Aprendizaje Profundo , Evaluación de la Discapacidad , Humanos , Imagen por Resonancia Magnética , Valor Predictivo de las Pruebas , Pronóstico , Índice de Severidad de la Enfermedad , Accidente Cerebrovascular/fisiopatología , Accidente Cerebrovascular/psicología , Máquina de Vectores de Soporte , Tomografía Computarizada por Rayos X
8.
J Stroke Cerebrovasc Dis ; 29(10): 105133, 2020 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-32912566

RESUMEN

BACKGROUND: This study developed and validated a dynamic prediction model for survival after ischaemic stroke up to 1 year. METHODS: Patients with stroke (n = 425) who participated in a sub-study (2002-2004) from the South London Stroke Register (SLSR) were selected for model derivation. The model was developed using the extended Cox model with time-dependent covariates. The two temporal validation cohorts from SLSR included 1735 (1995-2002) and 2155 patients (2004-2016). The discrimination, calibration and clinical utility of the model were assessed. RESULTS: Six strong predictors were used in the model, namely, age, sex, stroke subtype, stroke severity and pre-stroke and post-stroke disabilities. The c-statistics was 0.822 at 1 year in the derivation cohort. The model had a fair performance with prognostic accuracies of 77%-83% in the validation 1 cohort and 70%-75% in the validation 2 cohort. A good calibration was observed in the derivation cohort. CONCLUSION: The proposed model can accurately predict survival up to 1 year after ischaemic stroke.


Asunto(s)
Isquemia Encefálica/diagnóstico , Técnicas de Apoyo para la Decisión , Accidente Cerebrovascular/diagnóstico , Adolescente , Adulto , Anciano , Isquemia Encefálica/mortalidad , Isquemia Encefálica/terapia , Femenino , Humanos , Londres/epidemiología , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Pronóstico , Estudios Prospectivos , Sistema de Registros , Reproducibilidad de los Resultados , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Accidente Cerebrovascular/mortalidad , Accidente Cerebrovascular/terapia , Factores de Tiempo , Adulto Joven
9.
Medicine (Baltimore) ; 99(38): e22200, 2020 Sep 18.
Artículo en Inglés | MEDLINE | ID: mdl-32957351

RESUMEN

The central lymph nodes of the neck are the most common sites of papillary thyroid carcinoma (PTC) but cannot be easily diagnosed preoperatively. Prophylactic central lymph node dissection (CLND), especially contralateral CLND, is not recommended in various guidelines due to its high risk. The aim of our study was to establish an objective point score based on preoperative and intraoperative data to guide the selection of patients for contralateral CLND.We retrospectively evaluated 1085 consecutive patients with PTC treated by thyroidectomy for inclusion in this study (the training cohort). Variables of contralateral central lymph node macro-metastasis (CLNMM) were investigated using univariate and multivariate analyses; subsequently, nomograms were developed and then validated in an independent cohort of patients (n = 326, the validation cohort).Univariate and multivariate analyses indicated that preoperative fine needle aspiration-proven ipsilateral lateral lymph node metastasis (LNM) (odds ratio [OR] 4.888, 95% confidence interval [CI] 1.587-41.280, P < .001) and cases with frozen-section pretracheal LNM (OR 19.015, 95% CI 2.949-186.040, P < .001) or Delphian LNM (OR 4.494, 95% CI 1.503-54.128, P < .001) were the 3 risk factors for contralateral CLNMM. A receiver operating characteristic curve indicated a cutoff value of 1 for the frozen-section pretracheal LNM number or the Delphian LNM number as a predictor of contralateral central lymph node metastasis (CLNM). The nomogram was then generated according to the 3 risk factors and well validated in the external cohorts, and the intraoperative frozen-section results were highly consistent with the postoperative pathological results.The proposed nomogram based on the 3 factors showed a good prediction of contralateral CLNMM in PTC.


Asunto(s)
Escisión del Ganglio Linfático , Ganglios Linfáticos/patología , Cáncer Papilar Tiroideo/patología , Neoplasias de la Tiroides/patología , Adulto , Técnicas de Apoyo para la Decisión , Femenino , Humanos , Masculino , Persona de Mediana Edad , Nomogramas , Curva ROC , Cáncer Papilar Tiroideo/cirugía , Neoplasias de la Tiroides/cirugía
10.
South Med J ; 113(8): 368-371, 2020 08.
Artículo en Inglés | MEDLINE | ID: mdl-32747962

RESUMEN

Coronavirus disease 2019 (COVID-19) rapidly led to global human devastation, including multiple deaths, sicknesses, and financial reverberations across many individuals and communities. As COVID-19 gained its foothold in the United States, medical school administrators, faculty, and students had to undergo rapid change to mitigate the disease spread, putting all parties in dubious situations. Medical school administrators had to make swift and judicious decisions that would best serve the student body and the diverse patient population at clinical sites. Medical schools with students practicing in rural, remote regions with a dearth of healthcare resources have even more complicated decisions to make in these unprecedented times. We provide an overview of rapid decision-making processes that can be used by curriculum leaders and medical school administrators to continue to meet accreditation requirements while attempting to keep medical students safe and prepared for graduation in response to the COVID-19 health crisis.


Asunto(s)
Infecciones por Coronavirus , Curriculum , Técnicas de Apoyo para la Decisión , Educación Médica/organización & administración , Pandemias , Neumonía Viral , Facultades de Medicina/organización & administración , Acreditación , Betacoronavirus , Educación Médica/normas , Humanos , Salud Rural , Estados Unidos/epidemiología
11.
Public Health Rep ; 135(1_suppl): 50S-56S, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-32735197

RESUMEN

In 2014, California passed Assembly Bill 966, which required condom access for persons incarcerated in all 35 California state prisons (33 men's and 2 women's prisons). The California Correctional Health Care Services and the Sexually Transmitted Disease Control Branch and the Office of AIDS of the California Department of Public Health collaborated in a prison administration-led multidisciplinary implementation workgroup. Our workgroup, representing public health, correctional health, legal and legislative affairs, labor relations, and prison staff members, participated in 4 planning meetings during May-September 2015. We surveyed prison staff members and incarcerated men to identify and address potential challenges; conceptualized a tamper-resistant condom dispenser; developed educational materials, frequently asked questions for staff members, and fact sheets for the public; and conducted forums for custody and medical staff members at each prison. Key lessons learned included the need for high-level custody support, engagement of labor unions early in the decision-making process, and flexibility within defined parameters for sites to determine best practices given their unique institutional population, culture, and physical layout. Condom access was initiated at 4 prisons in July 2015 and expanded incrementally to the remaining 29 men's prisons through July 2016. A total of 243 563 condoms were accessed in the men's prisons, for an average of 354 condoms per 1000 population per month. The start-up dispenser cost was $69 825 (735 dispensers at $95 each). We estimated an annual condom cost of $0.60 per person. Although staff members and incarcerated men expressed concern that this legislation would condone sex and provide repositories for contraband, no serious adverse incidents involving condoms were reported. California demonstrated that condom access is a safe, low-cost intervention with high uptake for a large correctional system and provided a replicable implementation model for other states. Prison condom programs have the potential to decrease transmission of sexually transmitted infections (STIs) among incarcerated persons and their communities, which are often disproportionately affected by STIs, HIV, and other chronic diseases.


Asunto(s)
Condones/provisión & distribución , Prisiones/organización & administración , Salud Pública , Enfermedades de Transmisión Sexual/prevención & control , California/epidemiología , Técnicas de Apoyo para la Decisión , Femenino , Infecciones por VIH/epidemiología , Infecciones por VIH/prevención & control , Educación en Salud/organización & administración , Humanos , Capacitación en Servicio/organización & administración , Sindicatos/organización & administración , Masculino , Prisiones/economía , Prisiones/normas , Desarrollo de Programa , Enfermedades de Transmisión Sexual/epidemiología
12.
Value Health ; 23(7): 831-841, 2020 07.
Artículo en Inglés | MEDLINE | ID: mdl-32762984

RESUMEN

OBJECTIVE: This study examines European decision makers' consideration and use of quantitative preference data. METHODS: The study reviewed quantitative preference data usage in 31 European countries to support marketing authorization, reimbursement, or pricing decisions. Use was defined as: agency guidance on preference data use, sponsor submission of preference data, or decision-maker collection of preference data. The data could be collected from any stakeholder using any method that generated quantitative estimates of preferences. Data were collected through: (1) documentary evidence identified through a literature and regulatory websites review, and via key opinion leader outreach; and (2) a survey of staff working for agencies that support or make healthcare technology decisions. RESULTS: Preference data utilization was identified in 22 countries and at a European level. The most prevalent use (19 countries) was citizen preferences, collected using time-trade off or standard gamble methods to inform health state utility estimation. Preference data was also used to: (1) value other impact on patients, (2) incorporate non-health factors into reimbursement decisions, and (3) estimate opportunity cost. Pilot projects were identified (6 countries and at a European level), with a focus on multi-criteria decision analysis methods and choice-based methods to elicit patient preferences. CONCLUSION: While quantitative preference data support reimbursement and pricing decisions in most European countries, there was no utilization evidence in European-level marketing authorization decisions. While there are commonalities, a diversity of usage was identified between jurisdictions. Pilots suggest the potential for greater use of preference data, and for alignment between decision makers.


Asunto(s)
Investigación sobre Servicios de Salud/organización & administración , Prioridad del Paciente , Mecanismo de Reembolso , Proyectos de Investigación , Evaluación de la Tecnología Biomédica/métodos , Tecnología Biomédica/economía , Conducta de Elección , Costos y Análisis de Costo , Toma de Decisiones , Técnicas de Apoyo para la Decisión , Europa (Continente) , Humanos , Proyectos Piloto , Encuestas y Cuestionarios
13.
Value Health ; 23(8): 1040-1048, 2020 08.
Artículo en Inglés | MEDLINE | ID: mdl-32828216

RESUMEN

The Institute for Clinical and Economic Review (ICER) in the United States recently published a 2020 update to its value assessment framework. We are commenting on the method by which the benefits of health interventions are integrated, relating to contextual considerations and other factors relevant to an intervention's value. We start by discussing the theoretical foundations of decision analysis and its extension to multiple criteria decision analysis (MCDA). Then we provide a detailed, evidence-based response to some of the claims made by ICER with regard to the use of MCDA methods and stakeholder engagement. Finally, we provide a number of recommendations on the use of quantitative decision analysis and decision conferencing that could be of relevance to the ICER methodology. Overall, we agree that some of the proposed changes by ICER are moving in the right direction toward improving transparency in the value assessment process, but these changes are probably inadequate. We advocate that more serious attention should be paid to the use of quantitative decision analysis together with decision conferencing for the construction of value preferences via group processes for the integration of an intervention's various benefit components.


Asunto(s)
Toma de Decisiones , Evaluación de la Tecnología Biomédica/organización & administración , Algoritmos , Análisis Costo-Beneficio , Técnicas de Apoyo para la Decisión , Humanos , Proyectos de Investigación , Estados Unidos
14.
Value Health ; 23(8): 1049-1055, 2020 08.
Artículo en Inglés | MEDLINE | ID: mdl-32828217

RESUMEN

OBJECTIVES: Using an example of an existing model constructed by the National Institute for Health and Care Excellence (NICE) to inform a real health technology assessment, this study seeks to demonstrate how a discretely integrated condition event (DICE) simulation can improve the implementation of Markov models. METHODS: Using the technical report and spreadsheet, the original model was translated to a standard DICE simulation without making any changes to the design. All original analyses were repeated and the results were compared. Aspects that could have improved the original design were then considered. RESULTS: The original model consisted of 32 copies (8 risk strata × 4 treatments) of the Markov structure, containing more than 6000 Microsoft Excel® formulas (18 MB files). Three aspects (nonadherence, scheduled treatment stop, and end of fracture risk) were handled by incorporating weighted averages into the cycle-specific calculations. The DICE implementation used 3 conditions to represent the states and a single transition event to apply the probabilities; 3 additional events processed the special aspects, and profiles handled the 8 strata (0.12 MB file). One replication took 16 seconds. The original results were reproduced but extensive additional sensitivity analyses, including structural analyses, were enabled. CONCLUSION: Implementing a real Markov model using DICE simulation both preserves the advantages of the approach and expands the available tools, improving transparency and ease of use and review.


Asunto(s)
Simulación por Computador , Cadenas de Markov , Modelos Estadísticos , Evaluación de la Tecnología Biomédica/organización & administración , Técnicas de Apoyo para la Decisión , Humanos , Probabilidad
15.
Value Health ; 23(8): 1087-1095, 2020 08.
Artículo en Inglés | MEDLINE | ID: mdl-32828222

RESUMEN

OBJECTIVES: The increasing incidence of esophageal adenocarcinoma (EAC) and the dismal prognosis has stimulated interest in the early detection of EAC. Our objective was to determine individuals' preferences for EAC screening and to assess to what extent procedural characteristics of EAC screening tests predict willingness for screening participation. METHODS: A discrete choice experiment questionnaire was sent by postal mail to 1000 subjects aged 50 to 75 years who were randomly selected from the municipal registry in the Netherlands. Each subject answered 12 discrete choice questions of 2 hypothetical screening tests comprising 5 attributes: EAC-related mortality risk reduction, procedure-related pain and discomfort, screening location, test specificity, and costs. A multinomial logit model was used to estimate individuals' preferences for each attribute level and to calculate expected rates of uptake. RESULTS: In total, 375 individuals (37.5%) completed the questionnaire. Test specificity, pain and discomfort, mortality reduction, and out-of-pocket costs all had a significant impact on respondents' preferences. The average expected uptake of EAC screening was 62.8% (95% confidence interval [CI] 61.1-64.5). Severe pain and discomfort had the largest impact on screening uptake (-22.8%; 95% CI -26.8 to -18.7). Male gender (ß 2.81; P < .001), cancer worries (ß 1.96; P = .01), endoscopy experience (ß 1.46; P = .05), and upper gastrointestinal symptoms (ß 1.50; P = .05) were significantly associated with screening participation. CONCLUSIONS: EAC screening implementation should consider patient preferences to maximize screening attendance uptake. Based on our results, an optimal screening test should have high specificity, cause no or mild to moderate pain or discomfort, and result in a decrease in EAC-related mortality.


Asunto(s)
Adenocarcinoma/diagnóstico , Técnicas de Apoyo para la Decisión , Detección Precoz del Cáncer/psicología , Neoplasias Esofágicas/diagnóstico , Prioridad del Paciente , Conducta de Elección , Análisis Costo-Beneficio , Femenino , Humanos , Modelos Logísticos , Masculino , Países Bajos
16.
Value Health ; 23(8): 979-984, 2020 08.
Artículo en Inglés | MEDLINE | ID: mdl-32828225

RESUMEN

BACKGROUND: Discrete choice experiments (DCEs) are commonly used to elicit patient preferences as marginal rates of substitution (MRSs) between treatment or health service attributes. Because these studies are increasing in importance, it is vital that uncertainty around MRS estimates is reported. OBJECTIVE: To review recently published DCE studies that elicit patient preferences in relation to MRS reporting and to explore the accuracy of using other reported information to estimate the uncertainty of the MRSs. METHODS: A systematic literature review of DCEs conducted with patients between 2014 and July 2019 was performed. The number of studies reporting coefficients, MRSs, standard errors (SEs), and confidence intervals was recorded. If all information was reported, studies were included in an analysis to determine the impact of estimating the SEs of MRSs using coefficients and assuming zero covariance, to determine the impact of this assumption. RESULTS: Two hundred and thirty-two patient DCEs were identified in the review; 34.1% (n = 79) reported 1 or more MRS and, of these, only 62.0% (n = 49) provided an estimate of the uncertainty. Of these studies, 16 contained enough information for inclusion in the analysis, providing 116 datapoints. Actual SEs were smaller than estimated SEs in 75.0% of cases (n = 87), and estimated SEs were within 25% of the actual SE in 59.5% of cases (n = 69). CONCLUSION: Uncertainty of MRS estimates is unreported in a substantial proportion of recently published DCE studies. Estimating the SE of a MRS by solely using the SEs of the utility coefficients is likely to lead to biased estimates of the precision of patient trade-offs.


Asunto(s)
Conducta de Elección , Análisis Costo-Beneficio/métodos , Análisis Costo-Beneficio/normas , Técnicas de Apoyo para la Decisión , Prioridad del Paciente , Toma de Decisiones , Humanos , Modelos Logísticos , Modelos Econométricos , Incertidumbre
17.
Medicine (Baltimore) ; 99(32): e21389, 2020 Aug 07.
Artículo en Inglés | MEDLINE | ID: mdl-32769870

RESUMEN

BACKGROUND: Shared decision making (SDM) is a process within the physician-patient relationship applicable to any clinical action, whether diagnostic, therapeutic, or preventive in nature. It has been defined as a process of mutual respect and participation between the doctor and the patient. The aim of this study is to determine the effectiveness of decision aids (DA) in primary care based on changes in adherence to treatments, knowledge, and awareness of the disease, conflict with decisions, and patients' and health professionals' satisfaction with the intervention. METHODS: A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was conducted in Medline, CINAHL, Embase, the Cochrane Central Register of Controlled Trials, and the NHS Economic Evaluation Database. The inclusion criteria were randomized clinical trials as study design; use of SDM with DA as an intervention; primary care as clinical context; written in English, Spanish, and Portuguese; and published between January 2007 and January 2019. The risk of bias of the included studies in this review was assessed according to the Cochrane Collaboration's tool. RESULTS: Twenty four studies were selected out of the 201 references initially identified. With the use of DA, the use of antibiotics was reduced in cases of acute respiratory infection and decisional conflict was decreased when dealing with the treatment choice for atrial fibrillation and osteoporosis. The rate of determination of prostate-specific antigen (PSA) in the prostate cancer screening decreased and colorectal cancer screening increased. Both professionals and patients increased their knowledge about depression, type 2 diabetes, and the perception of risk of acute myocardial infarction at 10 years without statins and with statins. The satisfaction was greater with the use of DA in choosing the treatment for depression, in cardiovascular risk management, in the treatment of low back pain, and in the use of statin therapy in diabetes. Blinding of outcomes assessment was the most common bias. CONCLUSIONS: DA used in primary care are effective to reduce decisional conflict and improve knowledge on the disease and treatment options, awareness of risk, and satisfaction with the decisions made. More studies are needed to assess the impact of shared decision making in primary care.


Asunto(s)
Toma de Decisiones Conjunta , Técnicas de Apoyo para la Decisión , Atención Primaria de Salud , Humanos
18.
Surgery ; 168(4): 601-609, 2020 10.
Artículo en Inglés | MEDLINE | ID: mdl-32739138

RESUMEN

BACKGROUND: Detection of cystic lesions of the pancreas has outpaced our ability to stratify low-grade cystic lesions from those at greater risk for pancreatic cancer, raising a concern for overtreatment. METHODS: We developed a Markov decision model to determine the cost-effectiveness of guideline-based management for asymptomatic pancreatic cysts. Incremental costs per quality-adjusted life year gained and survival were calculated for current management guidelines. A sensitivity analysis estimated the effect on cost-effectiveness and mortality if overtreatment of low-grade cysts is avoided, and the sensitivity and specificity thresholds required of methods of cyst stratification to improve costs expended. RESULTS: "Surveillance" using current management guidelines had an incremental cost-effectiveness ratio of $171,143/quality adjusted life year compared with no surveillance or operative treatment ("do nothing"). An incremental cost-effectiveness ratio for surveillance decreases to $80,707/quality adjusted life year if the operative overtreatment of low-grade cysts was avoided. Assuming a societal willingness-to-pay of $100,000/quality adjusted life year, the diagnostic specificity for high-risk cysts must be >67% for surveillance to be preferred over surgery and "do nothing." Changes in sensitivity alone cannot make surveillance cost-effective. Most importantly, survival in surveillance is worse than "do nothing" for 3 years after cyst diagnosis, although long-term survival is improved. The disadvantage is eliminated when overtreatment of low-grade cysts is avoided. CONCLUSION: Current management of pancreatic cystic lesions is not cost-effective and may increase mortality owing to overtreatment of low-grade cysts. The specificity for risk stratification for high-risk cysts must be greater than 67% to make surveillance cost-effective.


Asunto(s)
Análisis Costo-Beneficio , Quiste Pancreático/economía , Quiste Pancreático/cirugía , Guías de Práctica Clínica como Asunto , Adulto , Anciano , Anciano de 80 o más Años , Enfermedades Asintomáticas , Técnicas de Apoyo para la Decisión , Diagnóstico por Imagen/economía , Humanos , Hallazgos Incidentales , Cadenas de Markov , Persona de Mediana Edad , Quiste Pancreático/diagnóstico por imagen , Quiste Pancreático/mortalidad , Años de Vida Ajustados por Calidad de Vida , Medición de Riesgo/economía , Sensibilidad y Especificidad , Análisis de Supervivencia , Procedimientos Innecesarios
19.
PLoS One ; 15(8): e0236410, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-32797095

RESUMEN

The use and management of single use plastics is a major area of concern for the public, regulatory and business worlds. Focusing on the most commonly occurring consumer plastic items present in European freshwater environments, we identified and evaluated consumer-based actions with respect to their direct or indirect potential to reduce macroplastic pollution in freshwater environments. As the main end users of these items, concerned consumers are faced with a bewildering array of choices to reduce their plastics footprint, notably through recycling or using reusable items. Using a Multi-Criteria Decision Analysis approach, we explored the effectiveness of 27 plastic reduction actions with respect to their feasibility, economic impacts, environmental impacts, unintended social/environmental impacts, potential scale of change and evidence of impact. The top ranked consumer-based actions were identified as: using wooden or reusable cutlery; switching to reusable water bottles; using wooden or reusable stirrers; using plastic free cotton-buds; and using refill detergent/ shampoo bottles. We examined the feasibility of top-ranked actions using a SWOT analysis (Strengths, Weaknesses, Opportunities and Threats) to explore the complexities inherent in their implementation for consumers, businesses, and government to reduce the presence of plastic in the environment.


Asunto(s)
Monitoreo del Ambiente , Plásticos/toxicidad , Ríos/química , Contaminantes Químicos del Agua/toxicidad , Comportamiento del Consumidor , Técnicas de Apoyo para la Decisión , Contaminación Ambiental , Humanos , Plásticos/química , Reciclaje , Residuos/análisis , Contaminantes Químicos del Agua/química
20.
PLoS One ; 15(8): e0237639, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-32813717

RESUMEN

BACKGROUND: Risk prediction models allow clinicians to forecast which individuals are at a higher risk for developing a particular outcome. We developed and internally validated a delirium prediction model for incident delirium parameterized to patient ICU admission acuity. METHODS: This retrospective, observational, fourteen medical-surgical ICU cohort study evaluated consecutive delirium-free adults surviving hospital stay with ICU length of stay (LOS) greater than or equal to 24 hours with both an admission APACHE II score and an admission type (e.g., elective post-surgery, emergency post-surgery, non-surgical) in whom delirium was assessed using the Intensive Care Delirium Screening Checklist (ICDSC). Risk factors included in the model were readily available in electric medical records. Least absolute shrinkage and selection operator logistic (LASSO) regression was used for model development. Discrimination was determined using area under the receiver operating characteristic curve (AUC). Internal validation was performed by cross-validation. Predictive performance was determined using measures of accuracy and clinical utility was assessed by decision-curve analysis. RESULTS: A total of 8,878 patients were included. Delirium incidence was 49.9% (n = 4,431). The delirium prediction model was parameterized to seven patient cohorts, admission type (3 cohorts) or mean quartile APACHE II score (4 cohorts). All parameterized cohort models were well calibrated. The AUC ranged from 0.67 to 0.78 (95% confidence intervals [CI] ranged from 0.63 to 0.79). Model accuracy varied across admission types; sensitivity ranged from 53.2% to 63.9% while specificity ranged from 69.0% to 74.6%. Across mean quartile APACHE II scores, sensitivity ranged from 58.2% to 59.7% while specificity ranged from 70.1% to 73.6%. The clinical utility of the parameterized cohort prediction model to predict and prevent incident delirium was greater than preventing incident delirium by treating all or none of the patients. CONCLUSIONS: Our results support external validation of a prediction model parameterized to patient ICU admission acuity to predict a patients' risk for ICU delirium. Classification of patients' risk for ICU delirium by admission acuity may allow for efficient initiation of prevention measures based on individual risk profiles.


Asunto(s)
Enfermedad Crítica , Delirio/diagnóstico , Hospitalización/estadística & datos numéricos , Unidades de Cuidados Intensivos/estadística & datos numéricos , APACHE , Adulto , Anciano , Técnicas de Apoyo para la Decisión , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Curva ROC , Estudios Retrospectivos , Factores de Riesgo
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