Medical Decision Making (eBook)

Harold C. Sox, Michael C. Higgins, Douglas K. Owens (Autoren)

eBook Download: PDF

2013 | 2. Auflage
John Wiley & Sons (Verlag)
978-1-118-34157-5 (ISBN)

Infos

Medical Decision Making provides clinicians with a powerful framework for helping patients make decisions that increase the likelihood that they will have the outcomes that are most consistent with their preferences.

This new edition provides a thorough understanding of the key decision making infrastructure of clinical practice and explains the principles of medical decision making both for individual patients and the wider health care arena. It shows how to make the best clinical decisions based on the available evidence and how to use clinical guidelines and decision support systems in electronic medical records to shape practice guidelines and policies.

Medical Decision Making is a valuable resource for all experienced and learning clinicians who wish to fully understand and apply decision modelling, enhance their practice and improve patient outcomes.

'There is little doubt that in the future many clinical analyses will be based on the methods described in Medical Decision Making, and the book provides a basis for a critical appraisal of such policies.' - Jerome P. Kassirer M.D., Distinguished Professor, Tufts University School of Medicine, US  and Visiting Professor, Stanford Medical School, US

Harold C. Sox
Geisel School of Medicine at Dartmouth, Hanover, New Hampshire

Michael C. Higgins
Stanford University, Stanford, California

Douglas K. Owens
Department of Veterans Affairs Palo Alto Health Care System, Palo Alto, California; Stanford University, Stanford, California

Inhalt

Cover???????????????????????? 1
Title Page?????????????????????????????????? 5
Copyright???????????????????????????????? 6
Contents?????????????????????????????? 9
Foreword?????????????????????????????? 13
Preface???????????????????????????? 17
Chapter 1 Introduction?????????????????????????????????????????????????????????? 19
1.1 How may I be thorough yet efficient when considering the possible causes of my patient's problems??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 19
1.2 How do I characterize the information I have gathered during the medical interview and physical examination??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 20
1.3 How do I interpret new diagnostic information??????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 23
1.4 How do I select the appropriate diagnostic test??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 23
1.5 How do I choose among several risky treatment alternatives????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 24
1.6 Summary???????????????????????????????????? 24
Chapter 2 Differential diagnosis?????????????????????????????????????????????????????????????????????????????? 25
2.1 Introduction?????????????????????????????????????????????? 25
2.2 How clinicians make a diagnosis???????????????????????????????????????????????????????????????????????????????????? 26
2.3 The principles of hypothesis-driven differential diagnosis?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 29
2.3.1 The first step in differential diagnosis: listening and generating hypotheses 30
2.3.2 The second step in differential diagnosis: gathering data to test hypotheses 33
2.3.3 Hypothesis testing 35
2.3.4 Selecting a course of action 39
2.4 An extended example???????????????????????????????????????????????????????????? 39
2.4.1 Clinical aphorisms 43
Bibliography?????????????????????????????????????? 44
Chapter 3 Probability: quantifying uncertainty?????????????????????????????????????????????????????????????????????????????????????????????????????????? 45
3.1 Uncertainty and probability in medicine???????????????????????????????????????????????????????????????????????????????????????????????????? 45
3.1.1 The uncertain nature of clinical information 45
3.1.2 Probability: a language for expressing uncertainty 47
3.1.3 Probability: a means for interpreting uncertain information 49
3.1.4 When to estimate probability 51
3.1.5 Objective and subjective probability 51
3.2 Using personal experience to estimate probability???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 52
3.2.1 Direct probability assessment 53
3.2.2 Indirect probability assessment 53
3.2.3 Sources of error in using personal experience to estimate probability 56
3.3 Using published experience to estimate probability?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 64
3.3.1 Estimating probability from the prevalence of disease in patients with a symptom, physical finding, or test result 65
3.3.2 Estimating the probability of a disease from its prevalence in patients with a clinical syndrome 66
3.3.3 Clinical prediction rules for estimating probability 67
3.3.4 Limitations of published studies 73
3.4 Taking the special characteristics of the patient into account when estimating probability?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 75
Problems?????????????????????????????? 76
Bibliography?????????????????????????????????????? 77
Chapter 4 Understanding new information: Bayes' theorem???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 79
4.1 Introduction?????????????????????????????????????????????? 79
4.2 Conditional probability defined???????????????????????????????????????????????????????????????????????????????????? 82
4.3 Bayes' theorem?????????????????????????????????????????????????? 83
4.3.1 Derivation of Bayes’ theorem 83
4.3.2 Clinically useful forms of Bayes’ theorem 84
4.4 The odds ratio form of Bayes' theorem???????????????????????????????????????????????????????????????????????????????????????????????? 87
4.4.1 Derivation 87
4.4.2 The likelihood ratio: a measure of test discrimination 89
4.4.3 Using the odds ratio form of Bayes’ theorem 90
4.5 Lessons to be learned from Bayes' theorem???????????????????????????????????????????????????????????????????????????????????????????????????????? 94
4.5.1 Insights about interpreting diagnostic tests 94
4.5.2 The clinical significance of test specificity 96
4.5.3 The clinical significance of test sensitivity 98
4.6 The assumptions of Bayes' theorem???????????????????????????????????????????????????????????????????????????????????????? 100
4.7 Using Bayes' theorem to interpret a sequence of tests???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 102
4.8 Using Bayes' theorem when many diseases are under consideration???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 106
Problems?????????????????????????????? 108
Bibliography?????????????????????????????????????? 109
Chapter 5 Measuring the accuracy of diagnostic information?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 111
5.1 How to describe test results: abnormal and normal, positive and negative?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 111
5.2 Measuring a test's capability to reveal the patient's true state?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 116
5.2.1 How to measure test performance 116
5.2.2 Measures of concordance between index test and disease state 118
5.2.3 Measures of discordance between index test and disease state 119
5.3 How to measure the characteristics of a diagnostic test: a hypothetical case?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 124
5.3.1 Description of study 124
5.4 Pitfalls of predictive value?????????????????????????????????????????????????????????????????????????????? 127
5.5 Sources of biased estimates of test performance and how to avoid them???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 128
5.5.1 Study characteristics that help to insure that the results apply to usual practice 129
5.5.2 Study characteristics that insure unbiased, reproducible interpretation of the index test and the gold standard test 130
5.6 Spectrum bias???????????????????????????????????????????????? 134
5.6.1 The first phase of test evaluation: testing the ‘‘sickest of the sick’’ and the ‘‘wellest of the well’’ 134
5.6.2 The second phase of test evaluation: testing patients who have been referred for the gold standard test 135
5.6.3 Effects of spectrum bias 136
5.6.4 Effect of spectrum bias on the false-positive rate of a test 137
5.6.5 How to adjust for biased estimates of sensitivity and specificity 139
5.7 Expressing test results as continuous variables???????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 143
5.7.1 The distribution of test results in diseased and well individuals 144
5.7.2 The receiver operating characteristic curve 146
5.7.3 Using the ROC curve to compare tests 149
5.7.4 Setting the cut-off value for a test 149
5.8 Combining data from several studies of test performance???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 152
Problems?????????????????????????????? 155
Appendix: Derivation of the method for using an ROC curve to choose the definition of an abnormal test result 155
Bibliography?????????????????????????????????????? 158
Chapter 6 Expected value decision making?????????????????????????????????????????????????????????????????????????????????????????????? 161
6.1 An example?????????????????????????????????????????? 163
6.2 Selecting the decision maker?????????????????????????????????????????????????????????????????????????????? 166
6.3 Decision trees: structured representations for decision~problems?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 167
6.4 Quantifying uncertainty???????????????????????????????????????????????????????????????????? 170
6.5 Probabilistic analysis of decision trees?????????????????????????????????????????????????????????????????????????????????????????????????????? 174
6.6 Expected value calculations???????????????????????????????????????????????????????????????????????????? 176
6.7 Sensitivity analysis?????????????????????????????????????????????????????????????? 179
6.8 Folding back decision trees???????????????????????????????????????????????????????????????????????????? 181
Problems?????????????????????????????? 186
Bibliography?????????????????????????????????????? 186
Chapter 7 Markov models and time-varying outcomes???????????????????????????????????????????????????????????????????????????????????????????????????????????????? 188
7.1 Markov model basics???????????????????????????????????????????????????????????? 188
7.1.1 Markov Independence 191
7.1.2 Estimating transition probabilities 193
7.1.3 Age-adjusted survival probabilities 195
7.1.4 Determining life expectancy for time-invariant acyclic Markov models 198
7.1.5 Determining life expectancy by Monte Carlo simulation 202
7.2 Exponential survival model and life expectancy?????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 207
Problems?????????????????????????????? 216
Appendix: Mathematical details?????????????????????????????????????????????????????????????????????????? 218
Bibliography?????????????????????????????????????? 221
Chapter 8 Measuring the outcome of care-expected utility analysis???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 222
8.1 Basic concept-direct utility assessment???????????????????????????????????????????????????????????????????????????????????????????????????? 223
8.2 Sensitivity analysis-testing the robustness of utility analysis???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 228
8.3 Shortcut-using a linear scale to express strength of preference???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 230
8.4 Exponential utility-a parametric model?????????????????????????????????????????????????????????????????????????????????????????????????? 231
8.4.1 Exponential utility assessment 232
8.4.2 Assumption underlying the exponential utility model 233
8.4.3 Exponential utility and risk attitudes 234
8.5 Exponential utility with exponential survival???????????????????????????????????????????????????????????????????????????????????????????????????????????????? 236
8.6 Multidimensional outcomes-direct assessment???????????????????????????????????????????????????????????????????????????????????????????????????????????? 238
8.7 Multidimensional outcomes-simplifications???????????????????????????????????????????????????????????????????????????????????????????????????????? 241
8.7.1 Simplification: assume independence between preferences for length and quality of life 242
8.7.2 Simplification: assume the delta property 243
8.8 Multidimensional outcomes-quality-adjusted life years (QALY)?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 246
8.9 Comparison of the two models for outcomes with different length and quality???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 250
Problems?????????????????????????????? 253
Appendix: Mathematical details?????????????????????????????????????????????????????????????????????????? 255
Bibliography?????????????????????????????????????? 260
Chapter 9 Selection and interpretation of diagnostic tests?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 261
9.1 Taking action when the consequences are uncertain: principles and definitions???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 262
9.1.1 Three principles of decision making 262
9.1.2 The meaning of the treatment-threshold probability 264
9.2 The treatment-threshold probability???????????????????????????????????????????????????????????????????????????????????????????? 265
9.3 The decision to obtain a diagnostic test?????????????????????????????????????????????????????????????????????????????????????????????????????? 270
9.3.1 The criteria for diagnostic testing 270
9.3.2 A method for deciding to perform a diagnostic test 271
9.3.3 The threshold probabilities for testing 274
9.4 Choosing between diagnostic tests???????????????????????????????????????????????????????????????????????????????????????? 277
9.5 Choosing the best combination of diagnostic tests???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 279
9.5.1 Principles for choosing a combination of diagnostic tests 279
9.5.2 Using a computer to choose the best decision option 280
9.6 Setting the treatment-threshold probability???????????????????????????????????????????????????????????????????????????????????????????????????????????? 281
9.6.1 Estimate p* subjectively 281
9.6.2 Subjectively estimate the ratio of harms to benefits (H/B) 282
9.6.3 Use life expectancy to calculate p* 283
9.6.4 Use the patient’s utilities for the disease-treatment states to estimate treatment harms and benefits 285
9.7 Taking account of the utility of experiencing a test?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 293
9.8 A clinical case: test selection for suspected brain tumor???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 297
9.9 Sensitivity analysis?????????????????????????????????????????????????????????????? 299
Bibliography?????????????????????????????????????? 305
Chapter 10 Cost-effectiveness analysis and cost-benefit analysis?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 306
10.1 The clinician's conflicting roles: patient advocate, member of society, and entrepreneur???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 306
10.1.1 The clinician as advocate for the patient 306
10.1.2 Principles for allocating scarce resources 308
10.2 Cost-effectiveness analysis: a method for comparing management strategies?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 309
10.2.1 Using cost-effectiveness analysis to set institutional policy 309
10.2.2 Flat-of-the-curve medicine 315
10.3 Cost-benefit analysis: a method for measuring the net benefit of medical services?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 316
10.3.1 The distinction between cost–benefit analysis and cost-effectiveness analysis 316
10.3.2 Placing a monetary value on human life 317
10.3.3 Should clinicians take an interest in cost–benefit analysis? 319
10.4 Measuring the costs of medical care?????????????????????????????????????????????????????????????????????????????????????????????? 319
10.4.1 The direct costs of care 319
10.4.2 Productivity costs 321
10.4.3 Discounting future costs 321
Problems?????????????????????????????? 322
Bibliography?????????????????????????????????????? 323
Chapter 11 Medical decision analysis in practice: advanced methods?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 325
11.1 An overview of advanced modeling techniques?????????????????????????????????????????????????????????????????????????????????????????????????????????????? 325
11.1.1 When are advanced modeling approaches needed? 326
11.1.2 Types of modeling approaches 326
11.1.3 Choosing among modeling approaches 328
11.2 Use of medical decision-making concepts to analyze a policy problem: the cost-effectiveness of screening for HIV???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 329
11.2.1 The policy question 329
11.2.2 Steps of the analysis 329
11.2.3 Define the problem, objectives, and perspective 330
11.2.4 Identify alternatives and choose the modeling framework 330
11.2.5 Structure the problem, define chance events, represent the time sequence 331
11.2.6 Determine the probability of chance events 335
11.2.7 Value the outcomes 336
11.2.8 Estimate costs and discount outcomes 336
11.2.9 Calculate the expected utility, costs, and cost-effectiveness 337
11.2.10 Evaluate uncertainty 338
11.2.11 Address ethical issues, discuss results 340
11.3 Use of medical decision-making concepts to analyze a clinical diagnostic problem: strategies to diagnose tumors in the lung?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 341
11.3.1 Define the problem, objectives, and perspective 341
11.3.2 Identify alternatives and choose the modeling framework 341
11.3.3 Structure the problem, define chance events, represent the time sequence 341
11.3.4 Determine the probability of the chance events 343
11.3.5 Value the outcomes 343
11.3.6 Estimate costs and discount outcomes 344
11.3.7 Calculate expected utility, costs, and cost-effectiveness 345
11.3.8 Evaluate uncertainty 345
11.3.9 Address ethical issues, discuss results 348
11.4 Use of complex models for individual-patient decision making???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 348
11.4.1 The Alchemist decision support system 348
11.4.2 Challenges for individual-patient decision making 349
Bibliography?????????????????????????????????????? 351
Index???????????????????????? 355

Rezensionen

"Every physician is confronted daily with decision making. This book teaches the scientific principles of making decisions in clinical practice. For academic teachers." (Pediatric Endocrinology Reviews, 1 September 2014)

Produkt-Details

• Erscheint lt. Verlag: 3.5.2013
• Sprache: englisch
• Themenwelt: Medizin / Pharmazie ► Allgemeines / Lexika
• Themenwelt: Medizin / Pharmazie ► Medizinische Fachgebiete
• Schlagworte: available • Best • Clinical • Clinical Skills • Clinicians • Decision • Decisions • Edition • Entscheidung (Med.) • Evidence • Framework • Gesundheitspolitik, Risiken, Sicherheit des Patienten • Guidelines • Health Policy, Health Risk & Patient Safety • Infrastructure • Key • Klinische Fertigkeiten • likelihood • Medical • Medical Science • Medizin • New • patients • Powerful • Practice • Principles • provides
• ISBN-10: 1-118-34157-0 / 1118341570
• ISBN-13: 978-1-118-34157-5 / 9781118341575