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PubMed1999

International study of expert judgment on therapeutic use of benzodiazepines and other psychotherapeutic medications: IV. Therapeutic dose dependence and abuse liability of benzodiazepines in the long-term treatment of anxiety disorders.

Despite decades of relevant basic and clinical research, active debate continues about the appropriate extent and duration of benzodiazepine use in the treatment of anxiety and related disorders. The primary basis of the controversy seems to be concern among clinicians, regulators, and the public about the dependence potential and the abuse liability of benzodiazepines. This article reports systematically elicited judgments on these issues by a representative panel of 73 internationally recognized experts in the pharmacotherapy of anxiety and depressive disorders, a panel which was constituted by a multistage process of peer nomination. The criterion for inclusion at each stage was the nomination by at least two peers as one of the "professionally most respected physicians of the world with extensive experience and knowledge in the pharmacotherapy of anxiety and depressive disorders." Sixty-six respondents (90%) completed a comprehensive questionnaire covering a wide range of topics relevant to the therapeutic use of benzodiazepines and other medications that might be used for the same purposes. Overall, the expert panel judged that benzodiazepines pose a higher risk of dependence and abuse than most potential substitutes but a lower risk than older sedatives and recognized drugs of abuse. There was little consensus about the relative risk of dependence and abuse among the benzodiazepines. Differences between benzodiazepines with shorter and longer half-lives in inducing withdrawal symptoms are much less clear during tapered than during abrupt discontinuation. There was little agreement about the most important factors contributing to withdrawal symptoms and failure to discontinue benzodiazepines. The pharmacologic properties of the medication may be the most important contributors to withdrawal symptoms. In contrast, the clinical characteristics of the patient may be the most important contributors to failure to discontinue medication. The experts' judgment seems to support the widespread use of benzodiazepines for the treatment of bona fide anxiety disorders, even over long periods. The experts generally viewed dependence and abuse liability as clinical issues amenable to appropriate management, as for other adverse events related to therapy. However, more definitive clinical research on the remaining controversial issues is urgently needed to promote optimal patient care.

Anti-Anxiety Agents↗

PubMed1979

Validity of medical staff judgments in establishing quality assurance priorities.

The validation of a structured group judgment procedure to establish priorities for quality assurance activities was undertaken in six medical institutions in the United States. Validation focused on the extent to which health improvement could be documented by outcome-based projects focusing on priority topics. Predictive (criterion-related) validity was sought by analyzing five successively more stringent levels of evidence: 1) feasibility of implementing a quality assessment project within the topic areas selected by the prioity procedure; 2) accuracy of identifying health deficiencies or strengths; 3) verification of establishing correctable causes of health deficiencies; 4) capability of effecting significant improvement of health deficiencies; and 5) credibility of evidence that improvement achieved is directly attributable to corrective actions taken. Within the limits of generalizability, predictive validity was documented at every level of analysis. It is recommended that the structured group judgment process used in this study be more thoroughly evaluated and considered for quality assurance planning purposes.

Decision Making↗

PubMed1989

Disabling backache in France, Switzerland, and The Netherlands: contrasting sociopolitical constraints on clinical judgment.

A century has passed since clinicians assumed a linchpin role in the administration of programs to provide recourse and redress for persons suffering the illness of work incapacity. Medicine was asked to certify whether the illness was an injury in the absence of trauma, to ascertain whether further healing was possible, and to quantify the residual functional capacity. The response has been to force the vagaries of clinical judgment into the programmatic algorithm. No country has abandoned or redirected all three of these charges. Physicians have generally remained passive or intransigent as the society in which they function attempts to compensate for the indeterminate nature of these clinical questions. The current study compares the fashion in which the programs in Holland, Switzerland, and France have evolved in response to the clinical uncertainties. The Dutch have discarded the accident question. The Swiss emphasize the accident issue but consider the work-relatedness of the event to be irrelevant. The French have honed the traditional paradigm and have added a tier of clinical judgment within the program to monitor that without. These and other distinctions should cause all physicians to question their own convictions with regard to the three issues and, further, to question whether the basic paradigm is clinically flawed and therapeutically counterproductive.

Accidents, Occupational↗

PubMed2003

Sensitivity and specificity of the GDx: clinical judgment of standard printouts versus the number.

PURPOSE: The Number is a standard parameter of the GDx that reportedly distinguishes normal and glaucomatous eyes. The authors evaluated the sensitivity and specificity of the Number and examined whether expert clinical judgment of GDx printouts leads to a better separation. MATERIALS AND METHODS: Two experienced observers judged 800 GDx scans on 400 randomly presented printouts from 200 glaucoma patients and 200 age-matched normal subjects. The diagnosis was based on the symmetry analysis printout and was per patient rather than per eye. The observers assessed sensitivity for all glaucoma patients together, and separately for mild, moderate, and severe glaucoma. Their specificity was determined in the group of normal subjects. The same procedure was performed for the Number, at various critical values. RESULTS: Both observers discriminated better than the Number. At a critical value of 23, the specificity of the Number was 81.5%, which matched the lowest specificity of the 2 observers: 82.5% and 92.0% for observers 1 and 2, respectively. At these specificities, the sensitivity of the 2 observers and of the Number were 92.0%, 89.5%, and 85.5%, respectively. The sensitivity increased with the severity of glaucoma. The Kappa values for intraobserver agreement were 0.80 and 1.0. CONCLUSIONS: The Number yielded acceptable sensitivity and specificity values at a critical value of 23 in this test population. However, the clinical judgments of the printouts by both expert observers resulted in a better separation between normal and glaucomatous eyes, particularly in the group with mild glaucoma.

Adult↗

PubMed2004

Opposite visual field asymmetries for egocentric and allocentric spatial judgments.

The purpose of the present study was to investigate the relation between visual hemifields and spatial frames of reference, according to the idea that multiple representations of 3D space exist. Results from two experiments clearly show that an upper visual hemifield advantage only arises when allocentric spatial judgments are required in order to perform a location task, whereas a lower visual hemifield advantage arises when egocentric spatial judgments are required. Such a double dissociation was interpreted as due to the activity of two separate neural pathways operating specific transformations of visual input for different functional outputs: scene recognition, mostly relying on allocentric frames of reference and subserved by the ventral, occipito-temporal pathway of the visual system, and goal directed actions, mostly relying on egocentric systems and subserved by the dorsal, occipito-parietal pathway of the visual system.

Adult↗

PubMed2001

Differences in expert and lay judgments of risk: myth or reality?

This article evaluates the nine empirical studies that have been conducted on expert versus lay judgments of risk. Contrary to received wisdom, this study finds that there is little empirical evidence for the propositions (1) that experts judge risk differently from members of the public or (2) that experts are more veridical in their risk assessments. Methodological weaknesses in the early research are documented, and it is shown that the results of more recent studies are confounded by social and demographic factors that have been found to correlate with judgments of risk. Using a task-analysis taxonomy, a template is provided for the documentation of future studies of expert-lay differences/similarities that will facilitate analytic comparison.

Journal Article↗

PubMed2005

A structured expert judgment study for a model of Campylobacter transmission during broiler-chicken processing.

A structured expert judgment study was organized to obtain input data for a microbial risk-assessment model describing the transmission of campylobacter during broiler-chicken processing in the Netherlands. More specially, the expert study was aimed at quantifying the uncertainty on input parameters of this model and focused on the contamination of broiler-chicken carcasses with campylobacter during processing. Following the protocol for structured expert judgment studies, expert assessments were elicited individually through subjective probability distribution functions. The classical model was used to aggregate the individual experts' distributions in order to obtain a single combined distribution per variable. Three different weighting schemes were applied, including equal weighting and performance-based weighting with and without optimalization of the combined distributions. The individual experts' weights were based on their performance on the seed variables. Results of the various weighting schemes are presented in terms of performance, robustness, and combined distributions of the seed variables and some of the query variables. All three weighting schemes had adequate performance, with the optimized combined distributions significantly outperforming both the equal weight and the nonoptimized combined distributions. Hence, this weighting scheme, having adequate robustness, was chosen for further processing of the results.

Algorithms↗

PubMed1993

Consensus, self-other agreement, and accuracy in personality judgment: an introduction.

Consensus in personality judgment refers to the agreement with which two people (or more) can describe the personality of another; self-other agreement refers to the similarity between personality descriptions by the self and by others; and accuracy refers to the degree to which personality descriptions capture real attributes of the persons described. After years of focusing on other subjects, researchers recently have renewed their interest in these three topics. Current empirical research is philosophically diverse and includes studies incorporating pragmatic, constructivist, and realist approaches. Other research is resolving long-standing methodological problems and providing new analytic techniques for the study of consensus, self-other agreement, and accuracy. This special issue includes articles exemplifying all of these research approaches and documents that a new wave of research on consensus, self-other agreement, and accuracy in personality judgment now comprises a burgeoning field that has finally come of age.

Humans↗

PubMed2006

Formation of social acceptability judgments and their implications for management of rare and little-known species.

Effective policies for management of rare and little-known species (RLKS) must be not only scientifically valid and cost-effective but also consistent with prevailing social beliefs and values. Limited public awareness of RLKS, however constrains efforts to frame such policies. Lacking public support, resistance to RLKS programs is likely, particularly when other uses and values are affected. The challenge lies in understanding how public judgments are formed, sustained, and altered. Although the lack of public support often is attributed to inadequate understanding of the scientific bases for policies, research indicates that judgments derive from a complex, albeit poorly understood, suite of factors, including context, trust, esthetics, and personal history. Steps that can enhance public understanding of RLKS management include (1) clarifying the rationale and impacts of policies on the species, (2) specifying the contextual setting, (3) outlining specific actions to be taken, and (4) identifying when and where policies will be employed. Failure to foster understanding and support will leave management dominated by conflict and continued species loss.

Animals↗

PubMedDate not supplied

Eliciting stated preferences for health-technology adoption criteria using paired comparisons and recommendation judgments.

OBJECTIVES: The principal aim of this study was to illustrate applying discrete-choice methods for eliciting preferences for technology adoption criteria, including threshold values for cost-effectiveness ratios. A secondary objective was to compare the criteria weights of a sample of industry stakeholders with the results obtained from a study of National Institute for Health and Clinical Excellence (NICE) recommendations. METHODS: We administered a two-stage stated-preference (SP) question format to a sample of respondents who have expertise in applying economic analysis to technology adoption decisions. We elicited paired comparisons and recommendation judgments for similar criteria from a sample of International Society for Pharmacoeconomics and Outcomes Research members. Respondents evaluated nine pairs of hypothetical drugs, first indicating which drug was "better," then indicating what they would recommend to a reimbursement authority such as the National Health Service. Stated-choice studies often obtain only paired-comparison judgments. RESULTS: Parameter estimates from the initial paired-comparison question indicate only incremental cost-effectiveness ratio and number of affected patients influence evaluations. These two factors have identical weights in the second recommendation question, but all four factors were considered in determining the recommendation threshold. Our sample was more willing than NICE to accept trade-offs between cost-effectiveness and other drug features and was less concerned about cost-effectiveness ratios and information uncertainty. Nevertheless, our sample was in agreement with NICE about the importance of the number of patients who would benefit as a criterion for influencing adoption recommendations. CONCLUSION: This study demonstrates that including a question allowing respondents the opportunity to reject both alternatives in a forced-choice paired comparison can be important for obtaining accurate preference estimates. Our results demonstrate that SP methods offer a feasible means of quantifying a broad set of valuations that incorporate the preferences of patient, citizen, payer, and other stakeholder groups.

Academies and Institutes↗

PubMed1995

Kansans' perceptions of health care reform: a qualitative study on coming to public judgment.

The purpose of this study was to analyze the discussion of participants from three Kansas town meetings on health care reform. Yankelovich's process of "coming to public judgment" was used to guide the research. In this study participants were in the process of the first two stages of public judgment: consciousness-raising and working through. Health care reform was described in six themes: access, bureaucracy, distribution, expectations, futility, and prevention. Health care needs and reform were described within the context of personal meaning for those attending the town meetings.

Data Collection↗

PubMed1995

Assessing diagnostic approaches to depression in medically ill older adults: how reliably can mental health professionals make judgments about the cause of symptoms?

OBJECTIVE: To evaluate the reliability of the DSM-IV approach and five other schemes for counting symptoms toward the diagnosis of depression in hospitalized medically ill older patients and to examine whether mental health professionals can reliably make judgments about the etiology (medical or psychological) of depressive symptoms. METHOD: A sample of 38 patients aged 60 years or older admitted to the general medicine, cardiology, or neurology services at Duke University Medical Center were evaluated for depression using a structured psychiatric interview and the Hamilton Depression Scale. Interrater reliability for the diagnostic schemes, for unstructured clinical diagnoses, and for determinations of the causes of individual depressive symptoms was assessed by three pairs of mental health professionals. RESULTS: Agreement between raters for structured diagnoses was high regardless of diagnostic strategy, with the DSM-IV approach being only slightly less reliable than the strict inclusive approach (Kappa 0.88 vs Kappa 1.0, respectively). For all diagnostic approaches, there was perfect agreement between raters for eight cases of major depression. Agreement for unstructured clinical diagnoses of depression (K = 0.50) was much lower than for the structured diagnoses. Agreement between raters on the etiology of individual depression criterion symptoms assessed by structured interview was greater than 80% for 14 of 19 symptoms. Correlation between raters' depression severity ratings on the Hamilton Scale using the DSM-IV etiologic approach was equivalent to that using the strict inclusive approach (0.98 vs 0.95, respectively). CONCLUSIONS: Mental health professionals can be trained to make judgments reliably about the cause (medical or psychological) of symptoms in hospitalized older medical patients. The "strict inclusive" and other diagnostic schemes for counting symptoms toward the diagnosis of depression have only marginal, if any, benefit compared with the current DSM-IV approach.

Age Factors↗

PubMed2006

Beyond substituted judgment: How surrogates navigate end-of-life decision-making.

OBJECTIVES: To characterize how surrogates plan to make medical decisions for others. DESIGN: Descriptive study using semistructured qualitative interviews. SETTING: Surrogates were interviewed by telephone from their homes. PARTICIPANTS: Fifty experienced surrogate decision-makers identified to make decisions for older, chronically ill veterans. MEASUREMENTS: Surrogates were asked to describe advance care planning conversations with loved ones and how they planned to make future medical decisions. Thematic content analysis was used to identify bases for decision-making. RESULTS: Surrogates described the motivators and the content of advance care planning conversations with loved ones. Surrogates described five bases for decision-making: (1) conversations (making decisions based on their knowledge of their loved ones' preferences), (2) relying on documents (referring to their loved ones' advance care directives), (3) shared experience (believing an "inner sense" would guide decisions because of shared lived experience with loved ones), (4) surrogates' own values and preferences about life, and (5) surrogates' network (enlisting the help of others). CONCLUSION: Although ethicists and clinicians expect surrogates to use substituted judgment or patients' best interests when making decisions, these data indicate that many surrogates rely on other factors such as their own best interests or mutual interests of themselves and the patient or intend to base substituted judgments on documents with which they have little familiarity.

Adult↗

PubMed1988

Expert scientific judgment and cancer risk assessment: a pilot study of pharmacokinetic data.

When high-dose tumor data are extrapolated to low doses, it is typically assumed that the dose of a carcinogen delivered to target cells is proportional to the dose administered to test animals, even at exposure levels below the experimental range. Since pharmacokinetic data are becoming available that in some cases question the validity of this assumption, risk assessors must decide whether to maintain the standard assumption. A pilot study of formaldehyde is reported that was undertaken to demonstrate how expert scientific judgment can help guide a controversial risk assessment where pharmacokinetic data are considered inconclusive. Eight experts on pharmacokinetic data were selected by a formal procedure, and each was interviewed personally using a structured interview protocol. The results suggest that expert scientific opinion is polarized in this case, a situation that risk assessors can respond to with a range of risk characterizations considered biologically plausible by the experts. Convergence of expert opinion is likely in this case of several specific research strategies ar executed in a competent fashion. Elicitation of expert scientific judgment is a promising vehicle for evaluating the quality of pharmacokinetic data, expressing uncertainty in risk assessment, and fashioning a research agenda that offers possible forging of scientific consensus.

Biological Availability↗

PubMed1991

Assessment of child psychopathology: relationships between different methods, different informants and clinical judgment of severity.

The purpose of this study was to assess the relationships between information on children's problem behavior obtained by different methods (rating scales and clinical interviews) and from different sources (adolescent, parents and teacher). From a sample of 132 14-year-old international adoptees and their parents, information was obtained via the Child Behavior Checklist (CBCL), the Youth Self-Report and the Teacher's Report Form, the Child Assessment Schedule, and the Graham and Rutter Parent Interview. Agreement between the CBCL and the clinical judgment of the severity of psychopathology was substantial. Assessment procedures providing data on the adolescents' functioning derived from different sources revealed less agreement than those derived from the same informant. Agreement was higher for externalizing than for internalizing behaviors. Data from different sources made unique contributions to clinicians' judgments of the severity of psychopathology.

Adolescent↗

PubMedDate not supplied

Nursing judgment: the key to pain assessment in critically ill children.

Pain assessment in critically ill children emphasizes the need to place expert nursing judgment prominently on the list of assessment strategies. The expert nurse is uniquely qualified to identify subtle responses to physiologic and environmental stimuli and to titrate analgesics and other pain relief strategies accordingly. While it is challenging to assess pain with limited verbal and behavioral cues, pain assessment is not only possible, but even more critical, when the available cues are subtle and can be easily overlooked or attributed to other causes. The question that sparked these comments reflects the passion I so often witness in intensive care nurses committed to eliminating pain as an emotional and physiological stressor for these vulnerable children. When that passion is empowered by evidence-based nursing judgment, children receive the best possible care.

Adolescent↗

PubMed1984

Ability to judge lung volumes at different CO2-drives for ventilation and the possible influence of such a judgment on the ventilatory CO2-responsiveness.

Possible influences of changes in the CO2-respiratory drive on the ability to judge lung volumes and the possible effects of such judgments on the ventilatory CO2-responsiveness were studied in healthy subjects. The psychophysical relationships between objective and subjective magnitudes of lung volumes were determined at normocapnia, at three different levels of hypercapnia (breathing 1-3% CO2 in air) and at hypocapnia (after volitional hyperventilation). The relationships, expressed by a power function with the mean exponent 1.5 (SD +/- 0.3), were analyzed with respect to slope, intercept and correlation coefficient of the regression lines. None of these parameters was affected by variations in end-tidal PCO2 or by the concomitant changes in ventilation. In the 'attentive' pre-judgment breathing (APJB) the ventilatory response to CO2 was lower than during non-attentive breathing in three or four subjects. It is speculated that in these subjects the CO2-responsiveness was depressed by the increased attention during APJB. The question whether volitional hyperventilation gave rise to any specific post-hyperventilatory breathing pattern was analyzed. The results showed that the majority of post-hyperventilatory breathing pattern was apnoeic or hypopnoeic in character.

Adolescent↗

PubMed1994

Effect of compression ratio in a slow-acting compression hearing aid: paired-comparison judgments of quality.

Paired-comparison judgments of quality were obtained from 20 hearing-impaired listeners (half with a small dynamic range and half with a large dynamic range) for speech-in-noise (vent, apartment, and cafeteria) processed through a slow-acting compression hearing aid. Compression ratio was varied (1, 1.5, 2, 3, 5, and 10:1). Compression threshold, attack time, and release time were fixed. Sound quality judgments were significantly affected by compression ratio, noise, and dynamic range. Preference decreased with increasing compression ratio. The selection of compression ratio. The selection of compression ratios < or = 2:1 was significantly higher than of compression ratios > 3:1. Less compression (no compression or 1.5:1) was preferred with the highest level noise (cafeteria noise) than with the lower level noises (vent or apartment). In particular, the small dynamic range group preferred compression with the vent and apartment noises (noise below the compression threshold), but preferred a linear hearing aid with the cafeteria noise (above the compression threshold). The large dynamic range group showed a slightly greater preference for the linear hearing aid for all three noises.

Adolescent↗