Medical Decision Making

How health professionals and patients make treatment decisions, and the barriers to, and facilitators of, effective decision making.

Non-surgical management of ovarian cancer: Prevalence and implications

Jun. 9, 2016

David I. Shalowitz, Andrew J. Epstein, Emily M. Ko, Robert L. Giuntoli

In Gynecologic Oncology, David Shalowitz and colleagues, including Andrew Epstein, analyze the prevalence of non-surgical treatment for ovarian cancer, the reasons behind this in cases where surgery would have been clinically appropriate, and implications for survival rates. The authors find that one in five patients with ovarian cancer do not undergo surgery, which goes against best-practice guidelines. Surgery has been shown to significantly improve survival rates for ovarian cancer compared with non-surgical treatment. The largest determinant of whether a patient had surgical...

Selective Hearing: Physician Ownership and Physicians’ Response to New Evidence

Jun. 4, 2016

David H. Howard, Guy David, and Jason Hockenberry

In the Journal of Economics & Management Strategy, Guy David and colleagues examine whether physicians who own their surgical practices respond to new medical evidence differently from physicians who work in hospital-owned practices. In 2002, a clinical trial demonstrated that knee surgery did not benefit patients with osteoarthritis, which led to an overall decrease in knee surgeries. The authors took advantage of this “information shock” in 2002 to whether assess the impact of physician vs. hospital ownership status on these surgical practice patterns. They identified all...

Cost-Effectiveness of Field Trauma Triage among Injured Adults Served by Emergency Medical Services

May. 25, 2016

Craig D Newgard, Zhuo Yang, Daniel Nishijima, K John McConnell, Stacy A Trent, James F Holmes, Mohamud Daya, N Clay Mann, Renee Y Hsia, Tom D Rea, N Ewen Wang, Kristan Staudenmayer, M. Kit Delgado

In the Journal of the American College of Surgeons, M. Kit Delgado and colleagues evaluate the cost-effectiveness of field trauma triage practices (the criteria used to decide whether to transport an injured patient to a major trauma center). The authors compare current triage practices with alternatives that meet national policy benchmarks set by the American College of Surgeons Committee on Trauma (a high-sensitivity field triage strategy that would miss no more than 5% of seriously injured patients) and a moderate sensitivity, high-specificity approach (in which at least 65% of...

"Chasing a Ghost": Factors that Influence Primary Care Physicians to Follow Up on Incidental Imaging Findings

May. 23, 2016

Hanna M. Zafar, Eva K. Bugos, Curtis P. Langlotz, Rosemary Frasso

In Radiology, Hanna Zafar and colleagues, including Rosemary Frasso, explore factors that influence how primary care providers (PCPs) communicate and manage incidental imaging findings. Through semistructured interviews, researchers explored concerns and perspectives of 30 PCPs on receiving and acting on incidental imaging findings. Many providers expressed frustration stemming from the “quagmire” of follow-up for incidental findings producing a large financial burden on the health care system. Although these PCPs believed that the majority of incidental findings were of limited...

Adjuvant Chemotherapy Use and Health Care Costs After Introduction of Genomic Testing in Breast Cancer

Research Brief
Feb. 3, 2016

The promise of personalized genomic testing is that it can reduce unnecessary care and costs by predicting which patients are most likely to benefit from a treatment. In this study of actual treatment patterns, LDI Senior Fellows Andrew Epstein and Peter Groeneveld and colleagues investigate how genomic testing of women with early-stage breast cancer affects subsequent chemotherapy use and medical spending in the year after diagnosis. After surgery, women with early-stage breast cancer face the decision of whether to undergo expensive and potentially toxic chemotherapy to prevent recurrence, although most will not have a recurrence. The 21-gene recurrence score test (RS) was developed in 2004 to predict this risk, and its use in clinical medicine is increasing. Epstein and Groeneveld find that genomic testing is associated with decreased use of chemotherapy and lower costs in younger patients, and slightly increased use of chemotherapy and higher costs in older patients. Genomic testing in actual practice may “rule out” chemotherapy in younger women, and “rule in” chemotherapy in older women.

Evidence synthesis activities of a hospital evidence-based practice center and impact on hospital decision making

Dec. 7, 2015

Kishore Jayakumar, Julia Lavenberg, Matthew Mitchell, Jalpa Doshi, Brian Leas, David Goldmann, Kendal Williams, Patrick Brennan, Craig Umscheid

In the Journal of Hospital Medicine, Kishore Jayakumar and colleagues, including Jalpa Doshi and Craig Umscheid, assess whether the evidence synthesized and locally disseminated by a hospital evidence-based practice center (EPC) impacts institutional decision-making. Looking at a large academic health care system, the authors examined the EPC’s database of systemic reviews and a survey on the EPC’s reports, which assessed them for their usability, impact and satisfaction. Of the 249 reviews completed by the EPC since its inception, the most common requests came from clinical...

Effect of Attending Practice Style on Generic Medication Prescribing by Residents in the Clinic Setting: An Observational Study

Sep. 17, 2015

Kira L. Ryskina, C. Jessica Dine, Esther J. Kim, Tara F. Bishop, Andrew J. Epstein

In the Journal of General Internal Medicine, Kira Ryskina and colleagues, including Jessica Dine and Andrew Epstein, assess whether the prescribing practices of attending physicians influence residents’ likelihood to prescribe brand-name medications. The authors assessed the effect of the supervising attending’s rate of brand-name prescribing in the preceding quarter on the likelihood of a resident prescribing a brand-name statin. After adjusting for patient-, physician-, and practice-level factors, the supervising attending’s brand-name prescribing rate in the quarter preceding...

Uptake and Impact of a Clinical Diagnostic Decision Support Tool at an Academic Medical Center

Aug. 24, 2015

John S. Barbieri, Benjamin French, Craig A. Umscheid

In Diagnosis, John Barbieri, Benjamin French and Craig Umscheid investigate whether the use of a differential diagnosis (DDX) generator within a health care system leads to an increase in unnecessary testing and specialty consultation. By providing access to a broad differential, DDX generators can potentially help clinicians overcome cognitive biases by directing them to diagnoses they might not have considered otherwise. However, as the tool suggests numerous potential diagnoses, its use could result in an increase in unnecessary testing and specialty consultation, and...

Variability Among US Intensive Care Units in Managing the Care of Patients Admitted With Preexisting Limits on Life-Sustaining Therapies

Jun. 1, 2015

Joanna Hart, Michael Harhay, Nicole Gabler, Sarah Ratcliffe, Caroline Quill, Scott Halpern

In JAMA Internal Medicine, Scott Halpern and colleagues investigate variance in end-of-life care in intensive care units (ICUs) by looking at a group of patients with presumably similar care preferences. The authors compared the care received at 141 ICUs by patients with pre-existing limits on life-sustaining treatments, and the proportions of such patients who received aggressive care. The care outcomes measured were: provision of cardiopulmonary resuscitation, new forms of life support, and the addition or removal of treatment limitations. Of the ICU admissions evaluated, 4.8% of...

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