Clinical decision making for VA ECMO weaning in patients with cardiogenic shock A formative qualitative study.

Weaning and liberation from VA ECMO in cardiogenic shock patients comprises a complex process requiring a continuous trade off between multiple clinical parameters. In the absence of dedicated international guidelines, we hypothesized a great heterogeneity in weaning practices among ECMO centers due to a variety in local preferences, logistics, case load and individual professional experience. This qualitative study focused on the appraisal of clinicians' preferences in decision processes towards liberation from VA ECMO after cardiogenic shock while using focus group interviews in 4 large hospitals. The goal was to provide novel and unique insights in daily clinical weaning practices. As expected, we found we a great heterogeneity of weaning strategies among centers and professionals, although participants appeared to find common ground in a clinically straightforward approach to assess the feasibility of ECMO liberation at the bedside. This was shown in a preference for robust, easily accessible parameters such as arterial pulse pressure, stable cardiac index ≥2.1 L/min, VTI LVOT and 'eyeballing' LVEF.

The effect of information on preferences stated in a choice-based conjoint analysis.

OBJECTIVE: The objective of the study was to investigate the effect of a priori information on preferences for treatment elicited in a discrete choice experiment. METHODS: A convenience sample of 100 subjects was randomly split into two groups. The groups received minimal or extensive information on the treatment of ankle and foot impairment in stroke. Then, they participated in a discrete choice experiment. Possible treatment was described using eight decision criteria with two to four levels each. Part-worth utility coefficients for the criteria levels, criteria importance and overall treatment preference were estimated. It was tested whether the amount of information that was received influenced the outcome of the discrete choice experiment. RESULTS: In the extensively informed group fewer reversals in the expected order of part-worth utilities were found. Criteria importance for four of the eight criteria and criteria importance ranking between the minimally and extensively informed subject groups were significantly different. The difference in part-worth utility of the levels had a minor effect on the predicted utility of the available treatments. CONCLUSION: The lower number of level rank reversals in the extensively informed subjects indicates a better understanding of outcome desirability and thus a better understanding of the decision task. The effect of more extensive information on predicted treatment preference was minimal. PRACTICE IMPLICATIONS: While interpreting the results of a discrete choice experiment, the effect of prior knowledge on the decision problem has to be taken into account. Although information seems to increase the understanding of the decision task, outcomes valuation can also be directed by information and more extensive information increases the cognitive burden which is placed on the subjects. Future research should focus on the exact nature and size of the effects and the results of this study should be clinically validated.

Decision for reconstructive interventions of the upper limb in individuals with tetraplegia: the effect of treatment characteristics.

STUDY DESIGN: Survey. OBJECTIVE: To determine the effect of treatment characteristics on the decision for reconstructive interventions for the upper extremities (UE) in subjects with tetraplegia. SETTING: Seven specialized spinal cord injury centres in the Netherlands. METHOD: Treatment characteristics for UE reconstructive interventions were determined. Conjoint analysis (CA) was used to determine the contribution and the relative importance of the treatment characteristics on the decision for therapy. Therefore, a number of different treatment scenarios using these characteristics were established. Different pairs of scenarios were presented to subjects who were asked to choose the preferred scenario of each set. RESULTS: Forty-nine subjects with tetraplegia with a stable C5, C6 or C7 lesion were selected. All treatment characteristics significantly influenced the choice for treatment. Relative importance of treatment characteristics were intervention type (surgery or surgery with functional electrical stimulation implant) 13%, number of operations 15%, in-patient rehabilitation period 22%, ambulant rehabilitation period 9%, complication rate 15%, improvement of elbow function 10%, improvement of hand function 15%. In deciding for therapy, 40% of the subjects focused on one characteristic. CONCLUSION: CA is applicable in Spinal Cord Injury medicine to study the effect of health outcomes and non-health outcomes on the decision for treatment. Non-health outcomes, which relate to the intensity of treatment, are equally important or even more important than functional outcome in the decision for reconstructive UE surgery in subjects with tetraplegia.

Preferences of general practitioners regarding an application running on a personal digital assistant in acute stroke care.

An application was developed to optimize information exchange in acute stroke care, with which general practitioners (GPs) could consult hospital emergency units. However, it was difficult to obtain clear preferences from GPs regarding the functional requirements of the information to be transferred or the architecture of the application. Thirteen GPs volunteered to take part in the study. The GPs used a personal digital assistant in their daily work for a period of six weeks when visiting stroke patients during their evening, night and weekend shifts. A conjoint analysis was conducted to obtain the least and most preferred characteristics of the application, to facilitate implementation on a larger scale. The main outcome was that GPs preferred the decision-support facilities and the presence of information about the patient's medical history.