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Biomedical subjects

D Rovner

Publications and source records attributed to D Rovner.

13 recordsLinked to original sources
PubMed2001

Decision analysis in patient care.

To help patients to fully participate in shared decision making is becoming an important goal in clinical practice and one which is receiving increasing attention in terms of the requisite skills and technological development. We discuss the potential application of decision analysis-a specific technology that has been introduced into clinical practice but to date only within research contexts-and examine the usefulness and feasibility of the technique for patients, particularly in settings where clinical presentations are diverse and characterised by uncertainty.

Decision Support Techniques↗
PubMed2001

Decision aids for people facing health treatment or screening decisions.

BACKGROUND: Decision aids are interventions designed to help people make specific and deliberative choices among options (including status quo) by providing (at a minimum) information on the options and outcomes relevant to a person's health status. A systematic review is needed to summarize what is known about their efficacy. OBJECTIVES: 1. To create an inventory of existing decision aids. 2. To conduct a systematic review of randomized controlled trials of decision aids aimed at improving people's decision making and outcomes. SEARCH STRATEGY: The following electronic databases were searched: MEDLINE, EMBASE, PsycINFO, CINAHL, Aidsline, Cancerlit, the Cochrane Controlled Trials Register. In addition, individuals known to be active in the field of decision support were contacted. SELECTION CRITERIA: We screened titles and abstracts for all interventions providing structured, detailed, and specific information on treatment or screening options and outcomes to aid decision making. Information about the decision aids was compiled in an inventory and those evaluated in a randomized controlled trial were reviewed in detail. DATA COLLECTION AND ANALYSIS: Using Cochrane review methods, two reviewers independently screened and extracted data on several evaluation criteria. Results of randomized trials were pooled using weighted mean differences and relative risks with all data analysed using a random effects model. MAIN RESULTS: Eighty-seven decision aids were identified. Twenty-three of them had been evaluated in 24 randomized controlled trials. Among the trials comparing decision aids to usual care interventions, decision aids performed better in terms of: a) greater knowledge of options in seven of seven studies (weighted mean difference (WMD = 19 out of 100, 95% confidence interval (CI): 13,25); b) more realistic expectations in two of three studies (RR=1.48 95%CI 1.02, 2.14); c) lower decisional conflict related to feeling informed in three of three studies (WMD = -9.0 of 100 95%CI: -15, -3); d) reducing the proportion of people who were passive in decision making in three of four studies (RR = 0.63, 95% CI: 0.5, 0.8). When simpler decision aids were compared to more detailed ones, the relative improvement was significant in: a) improved knowledge in two of seven studies (WMD = 4 out of 100, 95% CI: 2, 5); b) realistic expectations in two of two studies (relative risk (RR ranged from 1.5 95%CI: 1.3,1.8); and c) decisional conflict in one of two studies (WMD= -4 95% CI -8,-0.2). There was a consistent trend for decision aids to do no better than comparison interventions in affecting: satisfaction with the decision in five of six studies, satisfaction with the decision making process in four of five studies, and anxiety in four of five studies. Decision aids had a variable effect on which screening or treatment options were selected. Exposure to decision aids relative to controls resulted in a consistent non-significant trend toward reduced preference for major surgery over conservative options by 21 to 42 per cent in five of five studies; however, they had no impact on circumcision in two of two studies. For colon and prostate cancer screening choices, the results were inconsistent. Two studies have shown no impact on persistence with chosen option and few studies have shown significant benefits on general health outcomes (two of three studies), or disease-specific health outcomes (one of four studies). REVIEWER'S CONCLUSIONS: The number of decision aids is expanding, but there is considerable overlap in some areas leaving gaps in others. Trials of decision aids indicate that they are superior to usual care interventions in improving knowledge and realistic expectations of the benefits and harms of options; reducing passivity in decision making; and lowering decisional conflict stemming from feeling uninformed. When simpler versions of decision aids are compared to more detailed aids, the differences in knowledge are marginal but there are other benefits in terms of creating realistic expectations and in reducing decisional conflict. To date, decision aids have had little effect on anxiety or satisfaction with the decision making process or satisfaction with the decision. Their effects on choices vary with the decision. The effects on persistence with chosen therapies and health outcomes require further evaluation. The essential elements in decision aids for different groups and different types of decisions need to be established. Consensus needs to be reached regarding standards for developing and evaluating decision aids.

Decision Support Techniques↗
PubMed2000

Information in the palm of your hand.

Physicians need a way to access and organize personal, patient-related, and medical reference information. Hand-held computers are a practical solution that can make this information available at the point of care. We review the major types of hand-held computers and their software and recommend specific models based on physicians' needs. We also describe software for hand-held computers, with special attention to medical record and medical reference software.

Computers↗
PubMed1997

An educational intervention as decision support for menopausal women.

The purpose of this study was to develop and test a decision support intervention (DSI) to assist women to make and act on informed decisions that are consistent with their values in the area of menopause and hormone replacement therapy (HRT). Mode and intensity of intervention were tested in midlife women (N = 248), randomly assigned to one of three intervention formats: written information only, guided discussion, or personalized decision exercise. Data were collected over 12 months. Knowledge, decisional conflict, satisfaction with health care provider, and self-efficacy improved following intervention and were maintained for 12 months for all groups. Women's adherence to their own plans over 12 months was 59% (exercise), 76% (calcium intake), and 89% (HRT). Carefully written information is effective in promoting knowledge, adherence, and satisfaction among well-educated, interested women. It was concluded that women can understand complex information, including tradeoffs regarding treatment options. Women will adhere to their own plans, suggesting that consumer rather than provider plans may be the more appropriate gold standard for measuring adherence.

Adult↗
PubMed1995

Evaluating and improving the cost-effectiveness of the implantable cardioverter-defibrillator.

The implantable cardioverter defibrillator (ICD) is an expensive, widely used device for severe ventricular arrhythmias. Marginal cost-effectiveness analysis is a technique to examine the incremental cost of treatment strategy in relation to its effectiveness. In this study, we used this technique to analyze the cost-effectiveness of the ICD compared with that of electrophysiology (EP)-guided drug therapy and examined ways in which it may be improved. We analyzed Michigan Medicare discharge abstracts (1989 to 1992) and local physician visit, test, and ICD charges. Effectiveness was from 218 previously described patients with ICDs in whom the time of first event (first appropriate shock or death) was determined and presumed to represent "control" (EP-guided drug therapy) mortality. We assumed a 4-year life cycle for the ICD generator and 3.4% operative mortality and used a 5% discount to prevent value. Data were analyzed in a 1-month cycle Markov decision model over a 6-year horizon, and results were updated to 1993 dollars. ICD effectiveness was an increase in discounted mean life expectancy of 1.72 years. Cost-effectiveness was $31,100/year of life saved (YLS). Results were minimally or modestly sensitive to variations in preoperative mortality; resource use; consideration only of patients with ICDs who were receiving any antiarrhythmic drug or specifically amiodarone; and to a decrease in the percentage of first shocks that would equal death without the ICD until the assumed percentage decreased to < 38%. At ejection fraction of < 0.25 and > or = 0.25, cost-effectiveness was $44,000/YLS and $27,200/YLS, respectively, and without preimplant EP study was $18,100/ YLS.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1991

Capturing and clustering women's judgment policies: the case of hormonal therapy for menopause.

Two hundred sixty-five women estimated the likelihood that they would take estrogen plus progestin to alleviate menopausal symptoms when faced with hypothetical cases varying in degree of hot flashes and risk of osteoporosis and cancer. Clustering of their judgment policies revealed four groups of women with respect to their approach to this decision. These groups of women were significantly different from each other on educational level, perceived experience of stress, and attitudes toward menopause and use of medications. Willingness to take hormonal therapy across all cases was related to attitudes about, and knowledge of, menstruation, perceived stress, mother's experience with menstrual problems, severity of symptoms, and use of vitamins. While there have been previous attempts to cluster rater policies, the current study represents a novel attempt to understand the differences between people who appear to have different policies about a decision problem, in this case, whether or not to take hormone therapy to counter menopausal symptoms.

Attitude↗
PubMed1990

Women's use of information regarding hormone replacement therapy.

For perimenopausal women, an important decision is whether or not to use hormone replacement therapy (HRT). The decision is complex because HRT involves judgment in weighing gains and losses related to physiological risk. Gains involve relief of hot flashes and prevention of osteoporosis; losses include cancer mortality and side effects of medication. A policy-capturing study of 283 perimenopausal women showed that the factor of most frequent concern was relief of hot flashes. Cluster analyses identified four major groups. Group 4 had an n of 9 and the lowest R2, making interpretation of data questionable. The largest group responded to hot flashes alone; the second to hot flashes and osteoporosis; and the third to hot flashes, somewhat to osteoporosis, but also to side effects of estrogen/progestin therapy. Results indicate nursing interventions should anticipate differences in women's concerns and tailor counseling appropriately.

Climacteric↗
PubMed1989

Hepatitis and hematemesis complicating nicotinic acid use.

Nicotinic acid has a proven efficacy in the treatment of hypercholesterolemia. Therapeutic use of this water-soluble B vitamin has resulted in a survival benefit among patients enrolled in the Coronary Drug Project. Conversely, nicotinic acid has been associated with a high side-effect profile when used at therapeutic doses. Nevertheless, there are no previously reported cases of hematemesis temporally associated with nicotinic acid use. The authors report the case of a previously healthy 20-year-old man who developed hematemesis and hepatitis 1 week after self-initiating the daily consumption of 6 g of nicotinic acid. Supportive therapy and discontinuing nicotinic acid resulted in rapid clinical improvement in this patient. The clinical circumstances suggest a possible causal relationship between nicotinic acid consumption and his presenting problems. The use of large doses of nicotinic acid may be rapidly complicated by hematemesis and hepatitis.

Adult↗
PubMedDate not supplied

Menopausal women as decision makers in health care.

The findings of a preliminary analysis of data from a study now being conducted to design and evaluate an educational intervention to aid women in becoming more effective decision-makers regarding menopause, self-care strategies, and hormone replacement therapy (HRT), indicate that the lack of attention to the symptoms and health effects of menopause has resulted in frustration and dissatisfaction among women health care consumers. Women in the menopausal years are not informed adequately nor empowered to participate in decision making around issues related to their own health. They do not have the information they want and they do not know where to get it.

Estrogen Replacement Therapy↗
PubMedDate not supplied

Cost-effectiveness analysis in heart disease, Part II: Preventive therapies.

Cost-effectiveness analysis of preventive therapies are reviewed in the following categories: lipid lowering, hypertension, smoking cessation, exercise, and anticoagulation. From review of 8 analyses, cost-effectiveness of primary prevention via cholesterol lowering drugs is generally expensive, whereas that of secondary prevention generally is favorable. However, targeting by age, coexisting risk factors, and gender strongly influence results that are also sensitive to drug costs. Treatment of hypertension (5 analyses) is cost-effective in virtually all patient populations and circumstances and for a wide variety of drugs. It is more so with coexisting risk. Issues relating to compliance and drug costs are important. Smoking cessation (4 analyses) is highly cost-effective and worthwhile. However, data on recidivism are incomplete, and cessation may be more difficult to achieve in the general population versus study patients. In one analysis, an exercise program was found to be cost-effective in prevention of coronary heart disease. Anticoagulants have been analyzed in various circumstances. Their cost-effectiveness is favorable for prosthetic valves, although sensitive to imprecision in monitoring. It is also favorable for mitral stenosis in the presence of atrial fibrillation but not normal sinus rhythm. Cost-effectiveness of heparinization for prosthetic valve patients undergoing surgery is rather variable and depends on type of surgery (major versus minor) and type of valve. Many topics in anticoagulant therapy remain to be explored from a cost-effectiveness point of view.

Adult↗
PubMedDate not supplied

Cost-effectiveness analysis in heart disease, Part III: Ischemia, congestive heart failure, and arrhythmias.

Cost-effectiveness analyses were reviewed in the following diagnostic and treatment categories: acute myocardial infarction (MI) and diagnostic strategies for coronary artery disease (CAD), coronary artery bypass graft (CABG) surgery, percutaneous transluminal coronary angioplasty (PTCA), congestive heart failure (CHF), and arrhythmias. In the case of acute MI, coronary care units, as presently used, are rather expensive but could be made much more efficient with more effective triage and resource utilization; reperfusion via thrombolysis is cost-effective, as are beta-blockers and angiotensin-converting enzyme (ACE) inhibitors post-MI in appropriate patients. Cost-effectiveness of CAD screening tests depends strongly on the prevalence of disease in the population studied. Cost-effectiveness of CABG surgery depends on targeting; eg, it is highly effective for such conditions as left-main and three-vessel disease but not for lesser disease. PTCA appears to be cost-effective in situations where there is clinical consensus for its use, eg, severe ischemia and one-vessel disease, but requires further analysis based on randomized data; coronary stents also appear to be cost-effective. In preliminary analysis, ACE inhibition for CHF dominates, ie, saves both money and lives. Cardiac transplant appears to be cost-effective but requires further study. For arrhythmias, implantable cardioverter defibrillators are cost-effective, especially the transvenous device, in life-threatening situations; radiofrequency ablation is also cost-effective in patients with Wolff-Parkinson-White syndrome apart from asymptomatic individuals; and pacemakers have not been analyzed except in the case of biofascicular block, where results were variable depending on the situation and preceding tests.

Angioplasty, Balloon, Coronary↗
PubMedDate not supplied

Confidence intervals for cost-effectiveness ratios.

The problem of variability in computed cost-effectiveness ratios (CERs) is usually addressed by performing sensitivity analyses to determine the effects on these ratios of plausible ranges of values of input parameters. However, the sampling variation that exists in these estimated parameters can be utilized to obtain confidence intervals for cost-effectiveness ratios. As cost-effectiveness analysis becomes more widely used, new techniques need to be developed for establishing when a difference in strategies evaluated is meaningful. A first step is to establish the precision of the CER itself. The authors estimate the precision of a CER in the context of a statistical model in which the primary outcome is survival, with cost and effectiveness defined in terms of the underlying survival distribution (S). Effectiveness (alpha) is measured by life expectancy, restricted to a finite time horizon and discounted at a fixed rate r, alpha = integral of e-rtS(t)dt. Cumulative cost (beta) per patient is regarded as resource utilization and incurred randomly over time depending on the survival experience of the patient, beta = integral of e-rtS(t)dC(t), where C(t) is the total potential resources utilized up to time t. Average cost-effectiveness (ACE) of a single strategy is beta/alpha, and when comparing two strategies, the CER is delta beta/delta alpha, the ratio of the incremental cost to the difference in mean survival. Utilizing the sampling distribution of the Kaplan-Meier estimate of S yields standard errors and confidence intervals for ACE and CER. The technique is applied to survival data from 218 previously studied patients to assess 95% confidence intervals for the CER and ACE of the implantable cardioverter defibrillator as compared with electrophysiology-guided therapy.

Confidence Intervals↗