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Biomedical subjects

J G Dolan

Publications and source records attributed to J G Dolan.

10 recordsLinked to original sources
PubMed1992

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.

Barium Sulfate↗
PubMed1990

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.

Decision Support Techniques↗
PubMed1985

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.

Acute Disease↗
PubMed1985

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.

Adolescent↗
PubMedDate not supplied

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.

Ambulatory Care↗
PubMedDate not supplied

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.

Adult↗
PubMedDate not supplied

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.

Decision Making↗
PubMedDate not supplied

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.

Acute Disease↗