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PubMed1990

Computer-aided decision support--glittering prospects, practical problems, and Pandora's box.

This chapter explores some of the prospects for and problems of computer-aided decision support in clinical medicine, with special reference to acute abdominal pain of both surgical and gynaecological origin. The need for such systems is argued, and it is further demonstrated that their provision is both feasible and (where implemented) associated with tangible improvements in performance by inexperienced hospital doctors. The problems of implementation are nevertheless formidable and these are discussed.

Attitude to Computers↗
PubMed2004

Randomised trial of a decision aid and its timing for women being tested for a BRCA1/2 mutation.

The aim of the study was to evaluate the impact of a decision aid (DA) and its timing in women being tested for a BRCA1/2 mutation. Women with and without a previous history of cancer were included after blood sampling for genetic testing. The DA consisted of a brochure and video providing information on screening and prophylactic surgery. To evaluate the impact of the DA, women were randomised to the DA group (n=184), receiving the DA 2 weeks after blood sampling, or to the control group (n=184). To evaluate the impact of timing, mutation carriers who had received the DA before the test result (n=47) were compared to mutation carriers who received the DA after the test result (n=42). Data were collected on well-being, treatment choice, decision and information related outcomes. The impact of the DA was measured 4 weeks after blood sampling. The impact of timing was measured 2 weeks after a positive test result. The DA had no impact on well-being. Regarding decision related outcomes, the DA group more frequently considered prophylactic surgery (P=0.02) corroborated with higher valuations (P=0.04). No differences were found for the other decision related outcomes. Regarding information related outcomes, the DA group felt better informed (P=0.00), was more satisfied with the information (P=0.00), and showed more accurate risk perceptions. Timing of the DA had no effect on any of the outcomes. No interactions were found between the DA and history of cancer. In conclusion, women being tested for a BRCA1/2 mutation benefit from the DA on information related outcomes. Because timing had no effect, the DA is considered useful either before or after the test result.

Adult↗
PubMed2006

Men's theories about benign prostatic hyperplasia and prostate cancer following a benign prostatic hyperplasia decision aid.

OBJECTIVE: To use qualitative methods to explore audiotape evidence of unanticipated confusion between benign prostatic hyperplasia (BPH) and prostate cancer in using a videotape BPH treatment decision aid (DA). DESIGN: Qualitative analysis of semi-structured interviews and surveys originally collected to study men's interpretation of a DA. SETTING AND PARTICIPANTS: Community sample of college and noncollege educated African American and white men (age> or =50; n=188). MEASURES: Transcript analysis identified themes in men's comments about BPH and cancer. Surveys measured BPH general and prostate cancer-specific knowledge, literacy (Short Test of Functional Health Literacy in Adults), BPH symptoms, and demographics. RESULTS: In transcript analysis, 18/188 men spontaneously talked about BPH and cancer as being related to each other, despite explicit statements to the contrary in the video. Survey data suggest that up to 126/188 men (67%) persisted in misconceptions even after viewing the DA video. Three themes were identified in the transcripts: (1) BPH and cancer are equated, (2) BPH surgery is for the purpose of removing cancer, and (3) BPH leads to cancer. CONCLUSIONS: Overall knowledge increases with DA use may mask incorrect theories of disease process. Further research should identify decision support designs and clinical counseling strategies to address persistence of beliefs contrary to new information presented in evidence-based DAs.

Black or African American↗
PubMed2004

Heart to Heart: a computerized decision aid for assessment of coronary heart disease risk and the impact of risk-reduction interventions for primary prevention.

Heart to Heart is a computer-based decision aid for patients and providers that provides personalized, evidence-based information about coronary heart disease (CHD) risk and potential risk-reducing interventions. To develop Heart to Heart, the authors used Framing-ham risk equations and systematic reviews of risk-reducing interventions. The Web version was programmed using PHP: Hypertext Processor, a Web-based programming language, and has separate interfaces for providers and patients. The authors subsequently developed a modified version for personal digital assistants. Heart to Heart uses information about a patient's CHD risk factors (age, gender, total and high-density lipoprotein cholesterol levels, diabetes, smoking, systolic blood pressure, and left ventricular hypertrophy) to calculate risk of total CHD events over 5 or 10 years. Patients and providers can then examine the effect of introducing one or more risk-reducing interventions (aspirin, lipid-lowering drug therapy, antihypertensive medication, or smoking cessation) on the patient's CHD risk. Future research will be directed to determining whether Heart to Heart can improve utilization of effective CHD risk-reducing interventions.

Adult↗
PubMed2003

The effect of decision aids on the agreement between women's and physicians' decisional conflict about hormone replacement therapy.

The aim of this secondary analysis was to compare the effects of a tailored decision aid (DA) with those of a pamphlet on the agreement between women's and physicians' decisional conflict about hormone replacement therapy (HRT). A total of 40 physicians and 184 women provided data. The agreement between women's and physicians' decisional conflict scores was measured using the intraclass correlation coefficient (ICC). The ICC was higher for dyads in the DA group (ICC=0.44; 95% confidence interval (CI)=0.25-0.59) compared to the pamphlet group (ICC=0.28; 95% CI=0.06-0.47). When the average score of decisional conflict of women nested within a physician and of each physician were used, the ICC for the DA group and the pamphlet group was 0.41 (95% CI=-0.04 to 0.72) and 0.06 (95% CI=-0.41 to 0.49), respectively. Compared to pamphlets, DAs appear to improve the agreement between women's and physicians' decisional conflict about HRT.

Adult↗
PubMed1996

Decision aids in radiology.

Computer systems can help radiologists decide which tests to perform and which diagnoses to consider. Repositories of clinical data and general medical knowledge can provide information on demand for decision-making tasks; many of these information resources are available remotely via the Internet. Decision support systems can incorporate the techniques of artificial intelligence to apply their general knowledge to the features of a particular patient. Successful use of these technologies requires careful attention to design, implementation, and rigorous evaluation. Computer-based decision aids can improve the cost effectiveness and diagnostic accuracy of radiologic practice and are poised to play an important role in the future of radiology.

Decision Support Techniques↗
PubMed1997

A model for integrating image processing into decision aids for diagnostic radiology.

Advances in imaging techniques have been mirrored by advances in the use of computers to extract and interpret image data. Helping clinicians to make effective use of this superabundance of information is a key aim of medical informatics research. One approach is to incorporate digital images and image processing within a knowledge-based decision aid for radiologists. This paper describes a generic design for such aids. The work is based on an abstract model of decision-making which is used to organize the presentation of information from a knowledge base. We describe a system in which the model of decision-making is augmented to describe processes underlying image interpretation. The augmented model, implemented as a logic program, is used to control the application of image processing operators to detect and describe radiological signs. Through the use of this model we are able to combine information from image processing with information from a symbolic knowledge base. The operation of the model is illustrated by considering three different applications in the domain of breast X-rays or mammograms.

Humans↗
PubMed2006

Computer aided decision system for early detection of breast cancer.

BACKGROUND & OBJECTIVES: Mammography is currently the method of choice for early detection of breast cancer in women. However, the interpretation of mammograms is largely based on radiologist's opinion. In this study an attempt is made to develop an image processing algorithm for the detection of microcalcifications and also a computer based decision system for early detection of breast cancer. The proposed method deals with a novel approach for the development of a computer aided decision (CAD) system for early detection of breast cancer by mammogram image analysis. METHODS: The proposed method employs simple thresholding the region of interest and the use of filters for clear identification of microcalcifications. The method suggested for the detection of microcalcifications from a mammogram image segmentation and analysis was tested over several images taken from mini-MIAS (Mammogram Image Analysis Society, UK) database. The algorithm was implemented using Metlab codes programming and hence can work effectively on a simple personal computer with digital mammogram as stored data for analysis. RESULTS: The algorithm works faster so that any radiologist can take a clear decision about the appearance of microcalcifications by visual inspection of digital mammograms. The performance of the algorithm was tested over several images and the validation of results by visual inspection were done by an expert radiologist. Also, the system has given good detection rate as high as 78 percent. The performance analysis of the CAD algorithm was done by receiver operating characteristics (ROC) plot. INTERPRETATION & CONCLUSION: The CAD system suggested here was capable of detecting microcalcifications with a high detection rate, and thus could be used for early detection of breast cancer.

Breast Neoplasms↗
PubMed1994

A decision aid for referring patients with systolic murmurs for echocardiography.

OBJECTIVE: To describe the practice pattern of a group of primary care providers in ordering echocardiography for healthy patients and to derive a decision aid to identify patients with systolic murmurs who have significant cardiac lesions. DESIGN: Retrospective case review of clinical variables, including the demographic, historical, and physical examination features obtained from chart review of the physician evaluation prior to referral for echocardiography and the echocardiographic results, with both univariate and multivariate regression analyses used to identify variables predictive of positive echocardiographic outcomes and to derive a regression model. SETTING: General internal medicine clinic in an urban major teaching hospital. PATIENTS/PARTICIPANTS: 169 patients between the ages of 18 and 55 years selected retrospectively from medical records. MEASUREMENTS AND MAIN RESULTS: Symptoms and auscultatory findings were not predictive of positive echocardiographic outcomes among the patients referred for the test. For the patients who had systolic murmurs, a logistic regression model had three significant predictors of positive echocardiographic results: additional year of age (odds ratio: 1.08, 95% CI: 1.02-1.13; p = 0.007); male gender (odds ratio: 5.87, 95% CI: 1.99-17.3; p = 0.002); and murmur grade > or = 3 (odds ratio: 4.99, 95% CI: 1.27-19.6; p = 0.02). The receiver-operating characteristic (ROC) curve area for this model was 0.741. If women aged 35 years and less with murmur grades < or = 2 had not been referred, 47% of the echocardiographies could have been avoided while retaining a sensitivity of 90%. CONCLUSIONS: The study suggested that healthy patients with systolic murmurs are least likely to have positive echocardiographic results when they are young and female and have murmur grades < or = 2. More careful screening of this group might make unnecessary almost half of the echocardiographies yielding negative results ordered for healthy patients with systolic murmurs.

Adolescent↗
PubMed2003

Safety with access scaffolds: development of a prototype decision aid based on accident analysis.

PROBLEM: Accidents involving temporary access systems, particularly temporary scaffolds, account for a large proportion of injuries in the construction industry worldwide. METHOD: This paper outlines the development of a prototype decision aid (SCAFPASS, an abbreviation for Scaffold Planning Aid for System Safety) to promote access scaffold safety. It was guided by an examination of the root-causes and management deficiencies apparent in: (a) paper-based files of 186 access-related incidents held by the Health and Safety Executive (HSE) in the UK; and (b) computer-based files of 2,910 incidents appearing in the HSE database between 1997 to 2000. RESULTS: The more frequent root-causes included the fitting of defective components, unauthorized modification of the structure, omission of barriers, and errors resulting in simple, readily detectable structural faults. Common managerial deficiencies included failure to control risk, unsafe methods and procedures, and inadequate training and supervision. IMPACT ON INDUSTRY: SCAFPASS aims to avoid these root-causes by improving safety management from the outset and throughout all phases of a project.

Accidents, Occupational↗
PubMed1988

Artificial intelligence: a computerized decision aid for trauma.

A computerized decision support system has been developed to advise ATLS-trained surgeons on the initial definitive management of patients with penetrating injuries of the abdomen immediately following resuscitation and stabilization. The program was developed as an "expert system," using the techniques of artificial intelligence. It is able to suggest: the need for further examination; additional tests; diagnoses; and treatments. In this study, the advice offered by the expert system was compared to that of physicians-in-training. Five actual patient care situations were presented to the system and to 13 medical students and surgical residents: four MS-III, three PGY-I, three PGY-III, and three PGY-V. The suggestions of each of the 13 trainees, the advice of the expert system, and the actual management were blinded. Five surgeons versed in trauma and otherwise not involved in the project judged whether each of the 15 purported management plans was acceptable and ranked them in order of preference. Only the actual care and the advice from the system were judged acceptable for all five problems. The rankings of the expert system were better than those of any individual trainee. The differences were statistically significant for two of the three chief residents, five of nine residents overall, and all four students. This preliminary validation of a prototype expert system is encouraging for the prospect of a computerized decision support system that can help surgeons make initial definitive management plans for patients with major trauma.

Abdominal Injuries↗
PubMed2004

Helping people assess the health risks from lifestyle choices: comparing a computer decision aid with customized printed alternative.

Decisions about lifestyle play a key role in influencing health. Illnesses such as heart disease result from combinations of factors, making it hard for people to evaluate alternatives (e.g., knowing how much exercise might give similar benefit to eating more fruit and vegetables). Computers can provide customized risk leaflets and interactive displays, which may encourage people to explore potential lifestyle changes by showing the consequences for future health of specific combinations of lifestyle changes. This empirical study invited 24 adult volunteers to use the information from a customized leaflet or interactive display to advise hypothetical patients about lifestyle changes. Advisers used both leaflet and computer for different patients, with order counterbalanced across volunteers. It was found that more combinations of lifestyle factors were explored with the interactive display, especially by the younger volunteers, without this taking more time. Most of the older volunteers preferred interacting with the computer, and rated it as easier to use than the leaflet. It is concluded that easy to use computer interfaces can be devised that help people explore the health consequences of personal decisions about lifestyle, and that people prefer interactive assistance rather than using printed alternatives.

Adult↗
PubMed2006

Evaluation of a decision aid for families considering p53 genetic counseling and testing.

PURPOSE: Li-Fraumeni syndrome (LFS) is associated with p53 germline mutations, and carriers are at increased risk for multiple primary cancers. We evaluated outcomes following the administration of a video-based decision aid (DA) prior to clinical p53 genetic counseling and testing among persons who had previously participated in cancer genetics research. METHODS: Fifty-seven individuals at risk for a known p53 mutation completed baseline and post-DA measures of psychological outcomes, plus knowledge and attitudes regarding p53 genetic testing. Counseling and testing uptake also was recorded. RESULTS: At baseline, multivariate analysis showed that greater testing intention was associated with lower decisional conflict (P < 0.01). Compared with baseline data, multivariate analyses of post-DA outcomes showed that knowledge about LFS and genetic testing increased and decisional conflict related to testing decreased (P < 0.001). Mean cancer worries scores decreased among all participants (P < 0.001), and mean depression scores decreased for males (P < 0.05). Thirty-nine (68%) completed pre-test genetic counseling and 23 (40%) subsequently gave a blood sample for clinical genetic testing. CONCLUSION: This intervention was useful as an initial outreach and educational method for families considering p53 genetic testing, and may improve knowledge about LFS as well as psychological outcomes.

Adult↗
PubMed2004

Effect of a computer-based decision aid on knowledge, perceptions, and intentions about genetic testing for breast cancer susceptibility: a randomized controlled trial.

CONTEXT: As the availability of and demand for genetic testing for hereditary cancers increases in primary care and other clinical settings, alternative or adjunct educational methods to traditional genetic counseling will be needed. OBJECTIVE: To compare the effectiveness of a computer-based decision aid with standard genetic counseling for educating women about BRCA1 and BRCA2 genetic testing. DESIGN: Randomized controlled trial conducted from May 2000 to September 2002. SETTING AND PARTICIPANTS: Outpatient clinics offering cancer genetic counseling at 6 US medical centers enrolled 211 women with personal or family histories of breast cancer. INTERVENTIONS: Standard one-on-one genetic counseling (n = 105) or education by a computer program followed by genetic counseling (n = 106). MAIN OUTCOME MEASURES: Participants' knowledge, risk perception, intention to undergo genetic testing, decisional conflict, satisfaction with decision, anxiety, and satisfaction with the intervention. Counselor group measures were administered at baseline and after counseling. Computer group measures were administered at baseline, after computer use, and after counseling. Testing decisions were assessed at 1 and 6 months. Outcomes were analyzed by high vs low risk of carrying a BRCA1 or BRCA2 mutation. RESULTS: Both groups had comparable demographics, prior computer experience, medical literacy, and baseline knowledge of breast cancer and genetic testing, and both counseling and computer use were rated highly. Knowledge scores increased in both groups (P<.001) regardless of risk status, and change in knowledge was greater in the computer group compared with the counselor group (P =.03) among women at low risk of carrying a mutation. Perception of absolute risk of breast cancer decreased significantly after either intervention among all participants. Intention to undergo testing decreased significantly after either intervention among low-risk but not high-risk women. The counselor group had lower mean scores on a decisional conflict scale (P =.04) and, in low-risk women, higher mean scores on a satisfaction-with-decision scale (P =.001). Mean state anxiety scores were reduced by counseling but were within normal ranges for both groups at baseline and after either intervention, regardless of risk status. CONCLUSIONS: An interactive computer program was more effective than standard genetic counseling for increasing knowledge of breast cancer and genetic testing among women at low risk of carrying a BRCA1 or BRCA2 mutation. However, genetic counseling was more effective than the computer at reducing women's anxiety and facilitating more accurate risk perceptions. These results suggest that this computer program has the potential to stand alone as an educational intervention for low-risk women but should be used as a supplement to genetic counseling for those at high risk.

Adult↗
PubMed2006

A decision aid for GPs for the treatment of elderly male patients with lower urinary tract symptoms (LUTS).

BACKGROUND: GPs have four main treatment options for lower urinary tract symptoms (LUTS): watchful waiting, alpha-blockers, 5-alpha-reductase inhibitors or (referral for) surgery. Guidelines do not provide clear cut-off values for (combinations of) symptoms and physical examination results to decide which treatment is best. OBJECTIVE: (i) To develop a decision aid ('checklist') for GPs for the treatment of patients with LUTS. (ii) To assess its value for use in a primary care population. Materials and methods. Population-based cross-sectional study. Included were subjects with uncomplicated LUTS for whom treatment in primary care may be appropriate. [International Prostate Symptom Score (IPSS) > or = 8, no prior prostate surgery, prostate-specific antigen (PSA) value < 10 ng/ml]. For each subject the appropriateness of surgery and alpha-blocker treatment was determined using a previously validated formalized international expert panel judgement. Regression models using data available in primary care were constructed to predict the panel judgement. Subsequently these models were transformed into simple checklists. Finally, the efficiency of these checklists was calculated. RESULTS: The best checklists consisted of age, symptoms severity, type of symptoms, a quality of life score and PSA value. Assuming one would like to provide at least 95% of the subjects for whom a certain treatment is appropriate with this treatment (i.e. 'sensitivity' of the checklist > or = 95%), one can reach a positive predictive value of 50-60%. CONCLUSION: Simple checklists based on the judgement of experts regarding the most appropriate therapy can help GPs to advise their patients of a rational treatment strategy.

Adrenergic alpha-Antagonists↗
PubMed2000

The use of statistical parametric mapping (SPM96) as a decision aid in the differential diagnosis of dementia using 99mTc-HMPAO SPECT.

In this study standard patterns of cerebral perfusion based on classifications described in the literature have been chosen and the ability of experienced imaging specialists to categorise the 99m Tc HMPAO SPECT scans of patients referred to the department for investigation of dementia has been compared before and after the calculation of Statistical Parametric Maps (SPM - Wellcome Dept of Cognitive Neurology). The primary aim was to investigate whether SPM is an effective decision aid and whether it impacts on the confidence of image reporting. The secondary aim was to examine the influence of SPM on the agreement between image reporting and clinical diagnosis. The results showed that there was a slight decrease in agreement between the imaging specialists after the introduction of additional information from SPM (K=0.57 to K=0.5) and that agreement between imaging reporting (including information from SPM) and clinical diagnosis was moderate (K=0.28). This study was able to confirm that SPM is capable of producing meaningful significance maps of individual patients in a routine clinical environment. However, there was no overwhelming evidence that SPM was able to resolve many of the dilemmas associated with the use of SPECT for the differential diagnosis of dementia. In particular, interpretation of SPECT perfusion patterns in dementia is a bigger problem than the initial identification of abnormalities.

Journal Article↗