PubMed · 7835504
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A Antczak-Bouckoms, J F Tulloch. 1994. Towards improving third molar extraction decisions.. https://doi.org/10.1259/dmfr.23.2.7835504
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Natural disasters are caused by the exposure and vulnerabilities to natural hazards of people, infrastructure and economic activities. Analysis of these factors has permitted identification of countries and areas within them where disaster-related mortality and economic losses are likely in the future. These high-risk areas are candidates for increased attention to, and investment in, disaster risk identification, reduction and transfer. Plans are underway to further identify disaster risk levels and factors on national and subnational scales in high-risk countries to create evidence for improved risk management decision-making. In this paper, I review selected recent global and regional risk analyses to highlight findings, areas for improvement and next steps in the overall process of using disaster risk information for more effective risk management and cost-effective reduction of losses.
OBJECTIVE: To develop a set of quality criteria for patient decision support technologies (decision aids). DESIGN AND SETTING: Two stage web based Delphi process using online rating process to enable international collaboration. PARTICIPANTS: Individuals from four stakeholder groups (researchers, practitioners, patients, policy makers) representing 14 countries reviewed evidence summaries and rated the importance of 80 criteria in 12 quality domains on a 1 to 9 scale. Second round participants received feedback from the first round and repeated their assessment of the 80 criteria plus three new ones. MAIN OUTCOME MEASURE: Aggregate ratings for each criterion calculated using medians weighted to compensate for different numbers in stakeholder groups; criteria rated between 7 and 9 were retained. RESULTS: 212 nominated people were invited to participate. Of those invited, 122 participated in the first round (77 researchers, 21 patients, 10 practitioners, 14 policy makers); 104/122 (85%) participated in the second round. 74 of 83 criteria were retained in the following domains: systematic development process (9/9 criteria); providing information about options (13/13); presenting probabilities (11/13); clarifying and expressing values (3/3); using patient stories (2/5); guiding/coaching (3/5); disclosing conflicts of interest (5/5); providing internet access (6/6); balanced presentation of options (3/3); using plain language (4/6); basing information on up to date evidence (7/7); and establishing effectiveness (8/8). CONCLUSIONS: Criteria were given the highest ratings where evidence existed, and these were retained. Gaps in research were highlighted. Developers, users, and purchasers of patient decision aids now have a checklist for appraising quality. An instrument for measuring quality of decision aids is being developed.
CONTEXT: Limited information exists to direct clinical management after an implantable device has been put under advisory. A better understanding of the risks and benefits of device replacement compared with continued clinical follow-up would be helpful to clinicians. OBJECTIVE: Using the tools of decision analysis, to determine the best management approach (immediate device replacement vs continued monitoring) in the setting of a device advisory. DESIGN: A decision model was constructed to evaluate the risks and benefits associated with immediate device replacement compared with continued monitoring. MAIN OUTCOME MEASURES: Variables considered included indications for device implantation, anticipated course following device failure, device failure rates from the advisory ranging from 0.0001% to 1.0% per year, and device replacement mortality rates ranging from 0.10% to 1.00% per procedure. Device replacement was preferred to continued follow-up when replacement led to greater patient survival. RESULTS: The decision to replace a recalled device depends primarily on the advisory's estimated device failure rate and the likely effects of device failure on mortality. Procedural mortality is an important secondary factor, while patient age and remaining generator life have the least influence on the decision. For pacemaker-dependent patients, advisory device failure rates exceeding 0.3% warrant device replacement in most situations. In patients with implantable cardioverter-defibrillators for primary or secondary prevention, a failure rate associated with an advisory of 3.0% is needed to favor replacement in most cases, decreasing to close to 1.0% as procedural mortality rates decrease to 0.1% or risk of fatal arrhythmias increase to near 20% per year. In cases of pacemaker implantation for non-life-threatening situations (eg, carotid sinus hypersensitivity), most device advisories do not warrant device replacement. CONCLUSIONS: The decision to replace a device under advisory is determined primarily by the incidence of device malfunction and the likely effects of device failure. This analysis provides a framework for managing recalled devices in the context of device, patient, and institutional characteristics.