A survey of gynecologists' attitudes regarding decision making in the management of non-cancerous conditions that frequently result in hysterectomy.

OBJECTIVE: To explore attitudes of practicing gynecologists regarding making treatment decisions for patients with benign uterine conditions frequently treated with hysterectomy. DESIGN: Mailed survey. PARTICIPANTS: 66 gynecologists practicing in the Greater Rochester, New York, area. INTERVENTIONS: After reading brief vignettes, respondents indicated how they would treat patients with chronic pelvic pain, uterine leiomyomas, and abnormal uterine bleeding, and rated the importance of 24 considerations in making their treatment decisions on a 1-to-5 scale ranging from not important to extremely important. RESULTS: Fourteen considerations (58%) had group mean importance ratings higher than 3. Exploratory factor analysis identified four factors that accounted for 96% of the variance. Respondent gender, practice type, graduation from a U.S. vs a non-U.S. medical school, and opinion regarding roles of doctor and patient in making treatment decisions were associated with significant differences in factor scores. CONCLUSIONS: Gynecologists' attitudes toward hysterectomy decisions are complex, multifactorial, and variable. Depending on the extent to which these attitudes affect treatment decisions, differences among gynecologists in their clinical decision making processes could account for a substantial amount of the regional variability in hysterectomy use.

A method for evaluating health care providers' decision making: the Provider Decision Process Assessment Instrument.

Valid and reliable assessment of the clinical decision-making process is essential for the evaluation of decision aiding methods and effective quality assurance programs. The Provider Decision Process Assessment Instrument is a 12-item questionnaire that measures a health care provider's degree of comfort with a medical decision. Its measurement properties were studied in two general internal medicine practices. Reliability, measured using Cronbach's alpha, was 0.90 (95% Cl = 0.87 to 0.92). Construct validity was also high, with expected negative correlations ranging from -0.53 to -0.67. The instrument also satisfied standard criteria for item homogeneity and was readily completed by clinicians. These results suggest that the Provider Decision Process Assessment Instrument will prove to be a valuable tool for assessing medical decision making in busy clinical settings.

A survey of clinicians' opinions regarding the value of published decision analyses as sources of clinically useful information.

Published decision analyses avoid many of the practical problems thought to be contributing to the slow acceptance of clinical decision analysis. To assess clinicians' opinions regarding the usefulness of published decision analyses, 46 physicians at a large community teaching hospital judged how useful 13 proposed interventions would be in helping them make better clinical decisions. Although 48% of the respondents indicated that they clearly understood decision analysis, easy access to a published decision analysis was the lowest-ranked intervention, with 28% of the respondents indicating that it would be helpful. In contrast, 87% indicated that easy access to the latest review article, the highest-rated intervention, would be helpful. This finding suggests that the proposed practical barriers to the acceptance of clinical decision analysis are relatively unimportant. The success of efforts to foster clinical decision analysis will depend on the identification of the key factors impeding its acceptance by clinicians and the development of effective techniques to overcome them.

Preferences of pregnant women and physicians for 2 strategies for prevention of early-onset group B streptococcal sepsis in neonates.

OBJECTIVES: To assess preferences of pregnant women, pediatricians, and obstetricians for the policies of the American College of Obstetrics and Gynecology (ACOG) and American Academy of Pediatrics (AAP) for reducing the incidence of neonatal group B streptococcal (GBS) sepsis. DESIGN: An interactive interview using a computer-based decision-making model (analytic hierarchy process) and a self-administered survey assessing the interview process. SETTING: An obstetric clinic at a university center and offices of practicing physicians from the Birmingham, Ala, area. PARTICIPANTS: Ninety-two pregnant women selected by a systematic sampling technique and 40 pediatricians and 40 obstetricians selected randomly. MAIN OUTCOME MEASURE: Ranking of the ACOG and AAP policies and the 5 criteria on which the decision was based: risk of infection to an infant, knowledge of maternal GBS status, risk of anaphylaxis to mother, diagnostic tests received by healthy infants, and cost. Satisfaction with the interview process also was measured. RESULTS: Eighty-three women (90%), 40 pediatricians, and 40 obstetricians (100%) provided responses suitable for analysis. Sixty-seven pregnant women (81%), 26 pediatricians (65%), and 6 obstetricians (15%) preferred the AAP strategy. The ACOG policy was the preferred strategy by 34 (85%) obstetricians. The 3 groups ranked risk of infection in an infant as the most important criterion in their decisions. Ranks for the other criteria differed among the 3 groups. Women ranked knowledge of maternal GBS status more important than did pediatricians and obstetricians. Thirty obstetricians (75%), 35 pediatricians (87.5%), and 72 pregnant women (86.7%) liked the interview. Seventy-three women (88%), 29 pediatricians (72.5%), and 17 obstetricians (42.5%) thought physicians should use this type of interview to assist in managing patients. CONCLUSIONS: Pregnant women, pediatricians, and obstetricians had different priorities when making a decision about GBS policies. These differences led obstetricians to prefer a different policy than that of pediatricians and pregnant women. Obstetricians were less likely to endorse the use of this decision-making technique in their practice than were patients and pediatricians.

Are patients capable of using the analytic hierarchy process and willing to use it to help make clinical decisions?

The analytic hierarchy process (AHP) is a user-friendly technique that enables a decision marker to elicit subjective values and combine them with more objective data in an explicit, unbiased manner. To determine whether patients are capable of using and willing to use the AHP to help make clinical decisions, the author asked 20 volunteers to perform an AHP analysis of the choice among five screening regimens for colon cancer. The patients were categorized as capable if they completed the analysis in < or = 45 minutes and as willing if they indicated that they would prefer to go through this type of analysis before making a clinical decision. Eighteen (90%) were capable and willing. The difference between this result and 25%, the predefined null hypothesis, is significant: p = 1.6 x 10(-9). These results indicate that AHP-based decision-making aids are likely to be acceptable to and within the capabilities of many patients. If so, they could serve as practical tools for improving the clinical decision-making process.

Isoniazid prophylaxis: the importance of individual values.

To provide insight into the decision whether to use isoniazid prophylaxis in uncomplicated cases of positive tuberculin tests, the authors conducted a multicriteria decision analysis using the analytic hierarchy process. If reducing the chance of developing active tuberculosis is considered at least slightly more important than avoiding isoniazid-related side effects, isoniazid prophylaxis is the better strategy for all patients. If avoiding isoniazid-related side effects is considered at least slightly more important, no prophylaxis is the better strategy for all patients. If these two considerations are judged equally important, the better strategy depends on patient age, the anticipated effectiveness of isoniazid prophylaxis, and whether or not the patient is a recent tuberculin convertor. The tradeoff between avoiding active tuberculosis and avoiding isoniazid-related side effects is the most important factor in the decision regarding the proper management of patients with positive tuberculin tests. These results emphasize the importance of taking an individualized approach to the management of these patients.

Diagnostic strategies in the management of acute upper gastrointestinal bleeding: patient and physician preferences.

BACKGROUND: Routine diagnostic endoscopy is commonly obtained for low-risk patients with acute upper gastrointestinal bleeding despite evidence from controlled trials that it does not improve patient outcome. OBJECTIVE: To determine whether endoscopy is being overutilized for these patients or whether considerations not addressed in the trials could justify its widespread use. METHODS: Twenty-five patients recovering from a recent hemorrhage and 22 primary care physicians used the analytic hierarchy process to perform an individualized analysis regarding the diagnostic management of acute upper gastrointestinal bleeding. The results were used to determine whether routine endoscopy was consistent with each subject's interpretation of relevant data and judgments regarding the relative importance of five management goals. The authors then compared the proportion of subjects in each group who preferred endoscopy over two non-endoscopy strategies (upper gastrointestinal series and no routine diagnostic test) with 85%, the current rate of endoscopy at the authors' hospital. RESULTS: Endoscopy was preferred by 92% (97.5% CI: 70%-98%) of the patients and 55% (97.5% CI: 31%-77%) of the physicians. The patients ranked identifying the cause of bleeding the second most important management goal after avoiding a poor outcome from the acute bleeding episode. CONCLUSIONS: The current rate of diagnostic endoscopy is higher than would be expected based on physicians' preferences but quite consistent with patients' preferences. Patients regard knowledge of the bleeding site as important, even if this information will not affect management or prognosis. Attempts to assess the use of diagnostic endoscopy and other diagnostic tests should take both patient preferences and the pure value of diagnostic information into account.

Using the analytic hierarchy process (AHP) to develop and disseminate guidelines.

To be effective, practice guidelines must accommodate the unique circumstances of individual patients. This article describes how the analytic hierarchy process (AHP), a decision-making technique, could be used to create flexible guidelines by linking guideline developers and clinical decision makers as coworkers in a common decision-making process. The advantages of using this approach for guideline dissemination are discussed and compared with other methods for disseminating and implementing guidelines. The clinical feasibility of the AHP approach is also reviewed.

Can decision analysis adequately represent clinical problems?

A major weakness of medical decision analysis has been the inability of the commonly used single attribute utility models to adequately represent clinical decision making situations. To illustrate this problem, I reanalyzed a well known decision analysis that is widely interpreted as proof that two decision alternatives are equivalent in all clinically meaningful respects. The reanalysis was based on a more representative decision model made possible by the use of the analytic hierarchy process (AHP), a multiobjective decision making technique. The use of this model resulted in the identification of a clearly preferred alternative, indicating that the results of the original analysis have been widely misinterpreted. The degree to which a decision model represents clinical reality influences the correct interpretation of a decision analysis. Limited decision models can yield only limited conclusions. The use of more representative multiobjective decision models would improve the clinical usefulness of medical decision analyses.

Initial management of serious urinary tract infection: epidemiologic guidelines.

OBJECTIVE: To obtain information necessary for the development of initial antibiotic treatment guidelines for patients with serious urinary tract infections. DESIGN: Retrospective chart review. SETTING: The medical service of a 533-bed university-affiliated community hospital. PATIENTS: 253 unselected patients hospitalized between January 1985 and December 1987 given principal discharge diagnoses of urinary tract infection, pyelonephritis, or gram-negative rod bacteremia originating in the urinary tract. RESULTS: Three clinically distinct groups were identified: women under 50 years old, older women, and men. Escherichia coli was isolated from 93% of young women, 70% of older women, and 46% of men. Pseudomonas aeruginosa was isolated from 39% of men with one or more urinary tract risk factors, including recent or recurrent urinary tract infections and known genitourinary tract abnormality. The overall prevalence of Group D streptococci was only 1%. More than 20% of the patients in each group were bacteremic. In all groups, resistance to ampicillin and first-generation cephalosporins was common. Trimethoprim-sulfamethoxazole was active in 98% of young women and 85% of older women and men without urinary risk factors. CONCLUSIONS: Age and gender identify clinically important subgroups of patients with serious urinary tract infections. Pending culture results, all patients should be considered bacteremic, ampicillin alone should not be prescribed, and antibiotics effective against P. aeruginosa should be given to men, especially those with risk factors.

The analytic hierarchy process in medical decision making: a tutorial.

The analytic hierarchy process (AHP) is a quantitative decision making technique created especially for complicated, multicriteria decision problems. This report reviews the theoretical foundations of the AHP and shows how to use it in a step-by-step fashion.

Medical decision making using the analytic hierarchy process: choice of initial antimicrobial therapy for acute pyelonephritis.

The analytic hierarchy process (AHP) was used to determine which of seven recommended antibiotic regimens represented optimal initial therapy for a young woman hospitalized for treatment of acute pyelonephritis. The model included the following criteria: maximize cure, minimize adverse effects (broken down into very serious, serious, and limited), minimize antibiotic resistance, and minimize cost (divided into total cost and patient cost). The criteria were weighted according to judgments made by 61 practicing clinicians. Alternatives were compared relative to the criteria using published information on the expected frequencies of urinary pathogens and drug toxicity, local antibiotic sensitivities and antibiotic charges, and expert opinion regarding their propensities for inducing antimicrobial resistance. The analysis identified ampicillin combined with gentamicin as the optimal regimen. This study illustrates several features of the AHP that make it promising for use in medical decision making: its ability to incorporate multiple criteria into a formal decision model, its procedural simplicity, and its similarity to current patient management guidelines. Further studies to establish the role of the AHP in medical decision making are warranted.

Monitoring and improving the content of medical residents' ambulatory care experience: a microcomputer-based method using diagnosis clusters.

Changing patterns of medical practice necessitate increased experience in ambulatory settings for internal medicine residents. Residency program directors must monitor the content and balance of the ambulatory care experience. Evaluation of ambulatory care educational programs requires a concise method of describing the illnesses seen in each outpatient setting and of monitoring individual resident activities. The authors present an easily applied, microcomputer-based method of analysis using diagnosis clusters that has been found to be useful in evaluating and modifying the ambulatory care curriculum at their institution. It provides a concise description of individual ambulatory settings, affords an opportunity to compare each setting with national norms, and identifies areas of inadequate exposure in each resident's experience.

An evaluation of clinicians' subjective prior probability estimates.

The degree of consensus and the accuracy of subjective prior probability estimates made by 104 clinicians were examined. The clinicians' estimates were compared with objective prior probabilities obtained from published sources and actual patient outcomes. Each clinician made seven estimates based upon written case summaries abstracted from patient records. Consensus was measured by calculating estimate ranges and standard deviations. The clinicians' estimates varied widely: the smallest range was 80 (2%-82%); four of the seven probability ranges were greater than 90. The average standard deviation was 19.5. Using these prior probabilities and Bayes' theorem, widely varying posttest probabilities would result after many common diagnostic tests. Accuracy was measured using the Brier score, which ranges from 0 to 1; a score of 0 indicates perfect accuracy. The clinicians' Brier scores ranged from 0.05 to 0.57. The objectively determined probabilities achieved a Brier score of 0.11, better than that of 96% of the clinicians. Clinical experience did not consistently affect estimate accuracy or consensus. The clinicians' subjective estimates were inaccurate measures of the prior probability of disease. There was little consensus regarding disease likelihood among the clinicians. Objective prior probabilities were more accurate and less variable.

Routine laboratory testing for medical disorders in psychiatric inpatients.

We examined the clinical utility of routine admission laboratory testing for medical disorders in 250 psychiatric inpatients by using clinical criteria to classify laboratory abnormalities as true- or false-positive results. The mean number of tests per patient was 27.7. The mean percentage of true-positive results was 1.8%; the mean predictive value was 12%. When three clinically defined subgroups were examined, both measures of test performance varied in direct proportion to the pretest probability of medical disease. Eleven patients (4%) had important medical problems discovered through routine laboratory testing. A testing battery consisting of nine tests in women and 13 in men would have identified all of these patients. Our results suggest that extensive, routine testing for medical disorders in this setting is unnecessary and that more efficient and accurate testing strategies, based on clinical information, can and should be developed.

Early clinical signs identify low-risk patients with acute upper gastrointestinal hemorrhage.

Early identification of patients at low risk for poor outcome after acute upper gastrointestinal hemorrhage would allow reduction of diagnostic and therapeutic interventions. We identified six early predictors of good outcome: age less than 75 years, no unstable comorbid illness, no ascites found on physical examination, normal prothrombin time, and, within an hour after presentation, systolic blood pressure of 100 mm Hg or greater and nasogastric aspirate free of fresh blood. Presence of all six predictors defined the low-risk population. Among 162 patients in the development and retrospective validation phases of our study, all 74 low-risk patients had good outcomes. A prospective validation study of 111 patients further established the accuracy of our predictive method; only two of 52 low-risk patients had poor outcomes. Application of our method should allow more selective management of patients with acute upper gastrointestinal hemorrhage.

Hypertension, vascular headaches, and seizures after carotid endarterectomy. Case report and therapeutic considerations.

The following three unusual complications of carotid endarterectomy developed in a 64-year-old woman: vascular headaches, delayed hypertension, and seizures. beta-Blockade with propranolol hydrochloride had no beneficial effect on either the hypertension or the headaches. Peripheral alpha-blockade with prazosin hydrochloride resulted in prompt improvement in the patient's condition. Altered autonomic vascular control secondary to carotid sinus trauma is proposed as a possible causative mechanism for all three complications. The therapeutic implications are discussed. Based on this experience, we would caution against the use of unopposed beta-blockade in this setting and suggest that the role of prazosin in the initial management of postendarterectomy hypertension and vascular headache be explored.