Medical Decision Making

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

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...

Suggestibility of Oncologists’ Clinical Estimates

May. 1, 2015

David I. Shalowitz, John O. Schorge

In JAMA Oncology, David Shalowitz and John Schorge (Massachusetts General Hospital), assess the degree to which oncologists’ clinical estimates might be biased by extraneous information. For their study the authors sent surveys of different clinical scenarios to members of the New England and Mid-Atlantic Association of Gynecological Oncologists. Respondents were asked to assess the scenarios and provide an estimated life expectancy, evaluate other providers’ assessments, and indicate what treatments they would opt for. Results of the study show that clinicians are influenced by anchoring...

Predictors of Community Therapists’ Use of Therapy Techniques in a Large Public Mental Health System

Apr. 1, 2015

Rinad S. Beidas, Steven Marcus, Gregory A. Aarons, Kimberly E. Hoagwood, Sonja Schoenwald, Arthur C. Evans, Matthew O. Hurford, Trevor Hadley, Frances K. Barg, Lucia M. Walsh, Danielle R. Adams, David S. Mandell

In JAMA Pediatrics, Rinad Beidas and colleagues explore the effects of individual and organizational characteristics on therapists’ self-reported use of different therapy techniques - cognitive behavioral therapy (CBT), family therapy, and psychodynamic therapy techniques. The study focuses on the Philadelphia public mental health system, currently engaged in a large-scale effort to increase the use of CBT. The study results show that although both individual and organizational factors are important, the relative significance of the factors varies by treatment type. Key findings include...

The Use of Health Information Technology to Improve Care and Outcomes for Older Adults

Jan. 18, 2015

Kathryn H. Bowles, Patricia Dykes, George Demiris

In a commentary in Research in Gerontological Nursing, Kathryn Bowles and colleagues look at how nurse scientists are using health information technology, such as electronic health records (EHR) and decision support, to improve care. They highlight positive research findings, including that integrated EHR systems reduced hospital-acquired pressure ulcers by 13 percent. Or how the use of a discharge decision support system helped to identify whether older adults were likely to need post-acute services, such as skilled home care or skilled nursing facility care. Use of the system,...

Digital Marketing to Physicians: Policy Lags Behind Practice

Nov. 12, 2014

In a Perspective in today’s New England Journal of Medicine, David Grande, LDI's Co-Director of Health Policy, and colleagues write about new digital forms of pharmaceutical and medical device marketing to physicians. The same technologies that can be used to support clinical practice—such as electronic health records, social media, and mobile applications—can also be used to conduct market research and to market directly to physicians. Grande and colleagues write: