The Intersection of Evidence and Values in Clinical Guidelines: Who Decides What Constitutes Acceptable Risk in the Care of Children?

Opel, Douglas J.; Taylor, James A.; Phillipi, Carrie A.; Diekema, Douglas S.

doi:10.1542/hpeds.2012-0090

Cited by 6 publications

(3 citation statements)

References 29 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Particularly when there is a lack of consensus among health care professionals regarding the appropriate recommendation, universal recommendations in a guideline may not be appropriate [23,26-28]. Our findings support the use of explicit discussions in guidelines regarding the role of patient and family preferences, as demonstrated in clinical practice guidelines recently produced by the American Academy of Pediatrics [29-32].…”

Section: Discussionsupporting

confidence: 58%

Variability of physicians’ thresholds for neuroimaging in children with recurrent headache

et al. 2014

View full text Add to dashboard Cite

BackgroundWe sought to determine the extent to which physicians agree about the appropriate decision threshold for recommending magnetic resonance imaging in a clinical practice guideline for children with recurrent headache.MethodsWe surveyed attending physicians in Canada practicing in community pediatrics, child neurology, pediatric radiology, and pediatric neurosurgery. For children in each of six risk categories, physicians were asked to determine whether they would recommend for or against routine magnetic resonance imaging of the brain in a clinical practice guideline for children with recurrent headache.ResultsCompleted surveys were returned by 114 physicians. The proportion recommending routine neuroimaging for each risk group was 100% (50% risk), 99% (10% risk), 93% (4% risk), 54% (1% risk), 25% (0.4% risk), 4% (0.01% risk). Community pediatricians, physicians in practice >15 years, and physicians who believed they ordered neuroimaging less often than peers were less likely to recommend neuroimaging for the 1% risk group (all p < 0.05).ConclusionsThere is no consensus among pediatric specialists regarding the appropriate decision threshold for neuroimaging in a clinical practice guideline for children with recurrent headache. Because of the impact that individual threshold preferences may have on guidelines, these findings support the need for careful composition of guideline committees and consideration of the role of patient and family preferences. Our findings also support the need for transparency in guidelines regarding how evidence was translated into recommendations and how conflicts were resolved.

show abstract

Section: Discussionsupporting

confidence: 58%

Variability of physicians’ thresholds for neuroimaging in children with recurrent headache

et al. 2014

View full text Add to dashboard Cite

show abstract

“…The complete procedure of medication selection is described in S1 Fig. For each vignette, physicians estimated the TURN by answering a question inspired from studies describing the consequences of medication non-adherence [5,9,25–28] and methods of risk communication and assessment [29–31]: “The patient tells you that he/she skips a daily dose of this medication periodically . In your opinion , at what frequency of missing doses is the risk to his/her health unacceptable ?” Seven answers were proposed, ranging from 1 to 3 days per month (i.e., risk considered unacceptable by physicians with 1 to 3 daily doses missed per month), 1 to 3 days per week, and always acceptable regardless of the frequency.…”

Section: Methodsmentioning

confidence: 99%

Acceptable medication non-adherence: A crowdsourcing study among French physicians for commonly prescribed medications

2018

View full text Add to dashboard Cite

BackgroundAchieving good medication adherence is a major challenge for patients with chronic conditions. Our study aimed to assess the Threshold for Unacceptable Risk of Non-adherence (TURN), defined as the threshold at which physicians consider the health risks incurred by patients due to medication non-adherence unacceptable, for the most commonly prescribed drugs in France.MethodsWe conducted an online study using a crowdsourcing approach among French general practitioners and specialists from September 2016 to August 2017. Physicians assessed the TURN for various levels of missed doses by evaluating a series of randomly presented clinical vignettes, each presenting a given medication with a given therapeutic indication. For each “drug-indication group” (i.e., all drugs from the same pharmacological class with a similar therapeutic indication): 1) we described the distribution of physicians’ assessments, 2) we provided a summary estimate of the TURN, defined as the frequency of missed doses above which 75% of the physicians’ assessments were located; 3) we computed the number of pill boxes reimbursed in France in 2016 to put our results into context.ResultsWe collected a total of 5365 assessments from 544 physicians, each of whom evaluated a random sample among 528 distinct clinical vignettes. Estimates of the TURN varied widely across drug-indication groups, ranging from risk considered unacceptable with 1 daily dose missed per month (e.g., insulin for diabetes) to risk always considered acceptable (e.g., anti-dementia drugs). Drugs with an estimated TURN of over one missing daily dose per week represented 44.9% of the prescription volume of the medications assessed in our study.ConclusionsAccording to physicians, the impact of non-adherence may vary greatly. Patient-physician discussions on the variable consequences of non-adherence could lead to a paradigm shift by seeking to reach “optimal adherence” depending on drugs rather than unrealistic “perfect adherence” to all drugs.

show abstract

“…17,18 It is also apparent that these factors may not be easily distinguished, such as when value judgments are masqueraded as medical fact. 19,20 Lack of clarity on which factors compose a decision with real choice (and the propensity to conflate them) can have a fundamental influence on the practice of SDM; many decisions that should not be shared with patients are, and those that should be are not.…”

Section: Figurementioning

confidence: 99%

A 4-Step Framework for Shared Decision-making in Pediatrics

Opel

2018

Pediatrics

Self Cite

View full text Add to dashboard Cite

POTENTIAL CONFLICT OF INTEREST: The author has indicated he has no potential conflicts of interest to disclose. Shared decision-making (SDM) is a well-established component of patient-centered care, and yet, its application in pediatrics is poorly understood. Common features of pediatric decision-making are not completely addressed in current SDM models, such as the fact that the principal SDM participant is the patient's surrogate, who, unlike competent adult patients deciding for themselves, has limitations on decision-making authority. To address this gap and improve the practice of SDM in pediatrics, a practical 4-step framework is presented. In step 1, physicians are posed the following question for any discrete decision: does the decision include >1 medically reasonable option? If the answer is no, SDM is not indicated. If the answer is yes, physicians proceed to step 2 and answer the following question: does 1 option have a favorable medical benefit-burden ratio compared with other options? If yes, physician-guided SDM is appropriate. If no, parent-guided SDM is appropriate. For each SDM approach, the physician proceeds to step 3 and answers the following question: how preference sensitive are the options? This helps to determine the specific SDM approach in step 4, which ranges from a strong or weak version of physician-guided SDM to a strong or weak version of parent-guided SDM. Several decisional characteristics, if present, can also help calibrate the version of SDM used. Additional analyses are needed to consider the inclusion of adolescents into this SDM framework.

show abstract

The Intersection of Evidence and Values in Clinical Guidelines: Who Decides What Constitutes Acceptable Risk in the Care of Children?

Cited by 6 publications

References 29 publications

Variability of physicians’ thresholds for neuroimaging in children with recurrent headache

Variability of physicians’ thresholds for neuroimaging in children with recurrent headache

Acceptable medication non-adherence: A crowdsourcing study among French physicians for commonly prescribed medications

A 4-Step Framework for Shared Decision-making in Pediatrics

Contact Info

Product

Resources

About