Formulating Management Strategies Using Fast-and-Frugal Trees (A Decision Tool to Transform Clinical Practice Guidelines and Clinical Pathways into Decision Support at the Point of Care)

Djulbegovic, Benjamin; Hozo, Iztok

doi:10.1007/978-3-031-37993-2_5

Cited by 2 publications

(1 citation statement)

References 9 publications

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“…However, critics have pointed out deficiencies in the current development of practice guidelines. These include: (a) most guideline panels develop one recommendation at a time that are typically not connected in a coherent analytical framework, 2 (b) guideline development suffers from a “black‐box” operation—a process with defined inputs and outputs, but without full understanding of its internal workings, 3 (c) “the integration problem”—lack of a framework for explicit integration of factors, such as patient preferences, and trade‐offs between benefits, and harms, 3 and, (d) the recommendations apply to “average” patients while clinicians and their patients care about getting advice tailored to their individual circumstances 4,5 …”

Section: Introductionmentioning

confidence: 99%

Improving methods of clinical practice guidelines: From guidelines to pathways to fast‐and‐frugal trees and decision analysis to develop individualised patient care

Djulbegovic,

Hozo,

Cuker

et al. 2023

Evaluation Clinical Practice

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BackgroundCurrent methods for developing clinical practice guidelines have several limitations: they are characterised by the “black box” operation—a process with defined inputs and outputs but an incomplete understanding of its internal workings; they have “the integration problem”—a lack of framework for explicitly integrating factors such as patient preferences and trade‐offs between benefits and harms; they generate one recommendation at a time that typically are not connected in a coherent analytical framework; and they apply to “average” patients, while clinicians and their patients seek advice tailored to individual circumstances.MethodsWe propose augmenting the current guideline development method by converting evidence‐based pathways into fast‐and‐frugal decision trees (FFTs) and integrating them with generalised decision curve analysis to formulate clear, individualised management recommendations.ResultsWe illustrate the process by developing recommendations for the management of heparin‐induced thrombocytopenia (HIT). We converted evidence‐based pathways for HIT, developed by the American Society of Hematology, into an FFT. Here, we consider only thrombotic complications and major bleeding. We leveraged the predictive potential of FFTs to compare the effects of argatroban, bivalirudin, fondaparinux, and direct oral anticoagulants (DOACs) using generalised decision curve analysis. We found that DOACs were superior to other treatments if the FFT‐predicted probability of HIT exceeded 3%.ConclusionsThe proposed analytical framework connects guidelines, pathways, FFTs, and decision analysis, offering risk‐tailored personalised recommendations and addressing current guideline development critiques.

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Section: Introductionmentioning

confidence: 99%

Improving methods of clinical practice guidelines: From guidelines to pathways to fast‐and‐frugal trees and decision analysis to develop individualised patient care

Djulbegovic,

Hozo,

Cuker

et al. 2023

Evaluation Clinical Practice

Self Cite

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Converting IMPROVE bleeding and VTE risk assessment models into a fast-and-frugal decision tree for optimal hospital VTE prophylaxis

Djulbegovic,

Boylan,

Kolo

et al. 2024

Blood Advances

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Current hospital VTE (venous thromboembolism) prophylaxis for medical patients has been characterized by both underuse and, increasingly, overuse. The American Society of Hematology (ASH) has endorsed the use of risk assessment models (RAM) as an approach to individualize VTE prophylaxis as a way of balancing overuse (excessive risk of bleeding) and underuse (risk of avoidable VTE). ASH has endorsed IMPROVE (International Medical Prevention Registry on Venous Thromboembolism) risk assessment models - the only RAM to assess short-term bleeding and VTE risk in acutely ill medical inpatients. ASH, however, notes that no RAMs have been thoroughly analyzed for their effect on patient outcomes. We aimed to validate the IMPROVE models and adapt them into a simple, fast-and-frugal (FFT) decision tree to evaluate the impact of VTE prevention on health outcomes and costs. We employed three methods: the "best evidence" from ASH guidelines, a "learning health system paradigm" combining guideline and real-world data from the Medical University of South Carolina (MUSC), and a "real-world data" approach based solely on MUSC data retrospectively extracted from electronic records. We found the most effective VTE prevention strategy utilizes the FFT decision tree, guided by an IMPROVE VTE score of ≥ 2 or ≥ 4 and a bleeding score of < 7. This method could prevent 45% of unnecessary treatments, saving about $5 million annually for patients like the MUSC cohort. We recommend integrating the IMPROVE models into hospital electronic medical records as a point-of-care tool, thereby enhancing VTE prevention in hospitalized medical patients.

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Formulating Management Strategies Using Fast-and-Frugal Trees (A Decision Tool to Transform Clinical Practice Guidelines and Clinical Pathways into Decision Support at the Point of Care)

Cited by 2 publications

References 9 publications

Improving methods of clinical practice guidelines: From guidelines to pathways to fast‐and‐frugal trees and decision analysis to develop individualised patient care

Improving methods of clinical practice guidelines: From guidelines to pathways to fast‐and‐frugal trees and decision analysis to develop individualised patient care

Converting IMPROVE bleeding and VTE risk assessment models into a fast-and-frugal decision tree for optimal hospital VTE prophylaxis

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