Simple Decision Aid Research Articles

Predicting remission after acute phase pharmacotherapy in patients with bipolar I depression: A machine learning approach with cross-trial and cross-drug replication.

Interpatient variability in bipolar I depression (BP-D) symptoms challenges the ability to predict pharmacotherapeutic outcomes. A machine learning workflow was developed to predict remission after 8 weeks of pharmacotherapy (total score of ≤8 on the Montgomery Åsberg Depression Rating Scale [MADRS]). Supervised machine learning models were trained on data from BP-D patients treated with olanzapine (N = 168) and were externally validated on patients treated with olanzapine/fluoxetine combination (OFC; N = 131) and lamotrigine (LTG; N = 126). Top predictors were used to develop a prognosis rule informing how many symptoms should change and by how much within 4 weeks to increase the odds of achieving remission. An AUC of 0.76 (NIR:0.59; p = 0.17) was established to predict remission in olanzapine-treated subjects. These trained models achieved AUCs of 0.70 with OFC (NIR:0.52; p < 0.03) and 0.73 with LTG (NIR:0.52; p < 0.003), demonstrating external replication of prediction performance. Week-4 changes in four MADRS symptoms (reported sadness, reduced sleep, reduced appetite, and concentration difficulties) were top predictors of remission. Across all pharmacotherapies, three or more of these symptoms needed to improve by ≥2 points at Week-4 to have a 65% chance of achieving remission at 8 weeks (OR: 3.74, 95% CI: 2.45-5.76; p < 9.3E-11). Machine learning strategies achieved cross-trial and cross-drug replication in predicting remission after 8 weeks of pharmacotherapy for BP-D. Interpretable prognoses rules required only a limited number of depressive symptoms, providing a promising foundation for developing simple quantitative decision aids that may, in the future, serve as companions to clinical judgment at the point of care.

Abstract 14227: Development of a Tool To Improve Risk Stratification of Patients With Atrial Fibrillation in the Emergency Department

Introduction: Currently, no tool exists to help emergency department (ED) physicians determine which patients with atrial fibrillation (AF) may be low risk for adverse outcomes and potential candidates for expedited discharge. Hypothesis: A simple decision aid can assess 90-day risk for a combined outcome of mortality, stroke, or re-presentation to the ED in AF patients. Methods: Through multi-disciplinary meetings, clinically relevant and easily attainable factors were selected to risk stratify AF patients in the ED, including: primary ED diagnosis (AF or other), age, AF symptom severity (Canadian Cardiovascular Society - Symptom of AF [CCS-SAF]), heart rate, blood pressure, and laboratory assessment. Logistic regression analyses were used to develop a scoring tool. Results: Over 15 months (Jan 2015 - Mar 2016), 935 consecutive patients presenting to the ED of an academic medical center hospital (University of North Carolina) with AF were included in the cohort. Ninety days from presentation, there were 275 (29.4%) adverse events. In multivariable analyses, 4 factors were identified which independently associated events among all patients with AF: non-AF primary ED diagnosis, age, heart rate, and severe AF symptoms (CCS-SAF 4). Using a scoring tool with these 4 factors (range 0-18), a score ≥ 14 predicted events with 72% accuracy. Including only the 223 patients with a primary diagnosis of AF, using a scoring tool with 3 factors (age ≥ 70, heart rate ≥ 105, severe AF symptoms) a score ≥ 10 (range 0-13) predicted events with 78% accuracy (25% sensitivity, 95% specificity). Conclusions: A simple risk stratification scoring tool may be useful to determine patient disposition for AF patients in the ED. In patients with a primary diagnosis of AF, the scoring tool was particularly useful (95% specific) in identifying patients unlikely to have an event. Further analyses of larger data sets are required for validation.

Mobile apps as a sustainable shopping guide: The effect of eco-score rankings on sustainable food choice

Consumers often struggle to assess food's environmental impact. A product ranking based on a standardized scoring approach (aggregating multiple indicators) that is easily accessible, for instance, via a mobile app, could serve as a simple decision aid for consumers. However, to avoid information overload, research is needed in which format such information should be presented. This paper examines how different information levels of an eco-score ranking influence decision uncertainty and sustainable food choice. In an online experiment (n = 332, representative by age and gender), we compared a basic eco-ranking and an extended eco-ranking (eco-rank plus additional indicators: transportation distance and eco-certifications) against a control group (no eco-ranking) in three different food categories: milk, juice, and eggs. The basic eco-ranking successfully lowered decision uncertainty compared to the two other groups. In contrast, the extended eco-ranking did not reduce consumers' decision uncertainty level. Further, the basic (extended) eco-ranking increased the likelihood of choosing a sustainable product by 26 (17) percentage points compared to the control group. Thus, providing access to a simple eco-ranking can help avoid information overload and increase sustainable consumption.

The bilateral scrotal flap: Anatomical study and it's use for the management of inflammatory granulomas following custom-made injections

The management of 10 cases of penile inflammatory granulomas following a subcutaneous injection of non-absorbable substance for the purpose of penile augmentation is presented. We subsequently used the bilateral scrotal flaps to cover the post-excision skin defect. A simple decision aid chart outlining the management of penile foreign body injections is proposed. A total of 10 patients were included in this study. All required surgical management by penile degloving, followed by complete excision of the inflammatory granuloma and overlying skin. The dissection of 14 cadavers was carried out to study the blood supply to the anterior scrotal flap. Penile reconstruction was then performed using a bilateral scrotal flap in all but two cases. Post-operatively, the patients were followed up for a 1 year period. We obtained good results in terms of the aesthetic outcome with all of our ten patients with the area covered having similar color to penile skin. There were no major post-operative complications. There were two minor complications involving wound healing. Sensory function was maintained and no penile shortening or curvatures were noted, in addition all patients were satisfied with both the shape and function of the penis. Although much rarer, penile augmentation related complications are still seen in western countries. The treating doctor should be aware of its management. We had achieved acceptable outcomes in our experience with the bilateral scrotal flap. We believe it is a good and simple option for soft tissue coverage of the penis in cases following the complete inflammatory granuloma excision. It can achieve satisfactory aesthetic and functional results for this group of patients.

Citizens Versus the Internet: Confronting Digital Challenges With Cognitive Tools

The Internet has evolved into a ubiquitous and indispensable digital environment in which people communicate, seek information, and make decisions. Despite offering various benefits, online environments are also replete with smart, highly adaptive choice architectures designed primarily to maximize commercial interests, capture and sustain users’ attention, monetize user data, and predict and influence future behavior. This online landscape holds multiple negative consequences for society, such as a decline in human autonomy, rising incivility in online conversation, the facilitation of political extremism, and the spread of disinformation. Benevolent choice architects working with regulators may curb the worst excesses of manipulative choice architectures, yet the strategic advantages, resources, and data remain with commercial players. One way to address some of this imbalance is with interventions that empower Internet users to gain some control over their digital environments, in part by boosting their information literacy and their cognitive resistance to manipulation. Our goal is to present a conceptual map of interventions that are based on insights from psychological science. We begin by systematically outlining how online and offline environments differ despite being increasingly inextricable. We then identify four major types of challenges that users encounter in online environments: persuasive and manipulative choice architectures, AI-assisted information architectures, false and misleading information, and distracting environments. Next, we turn to how psychological science can inform interventions to counteract these challenges of the digital world. After distinguishing among three types of behavioral and cognitive interventions—nudges, technocognition, and boosts—we focus on boosts, of which we identify two main groups: (a) those aimed at enhancing people’s agency in their digital environments (e.g., self-nudging, deliberate ignorance) and (b) those aimed at boosting competencies of reasoning and resilience to manipulation (e.g., simple decision aids, inoculation). These cognitive tools are designed to foster the civility of online discourse and protect reason and human autonomy against manipulative choice architectures, attention-grabbing techniques, and the spread of false information.

Emergency department patients with weakness or fatigue: Can physicians predict their outcomes at the front door? A prospective observational study.

BackgroundGeneralized weakness and fatigue are underexplored symptoms in emergency medicine. Triage tools often underestimate patients presenting to the emergency department (ED) with these nonspecific symptoms (Nemec et al., 2010). At the same time, physicians’ disease severity rating (DSR) on a scale from 0 (not sick at all) to 10 (extremely sick) predicts key outcomes in ED patients (Beglinger et al., 2015; Rohacek et al., 2015). Our goals were (1) to characterize ED patients with weakness and/or fatigue (W|F); to explore (2) to what extent physicians’ DSR at triage can predict five key outcomes in ED patients with W|F; (3) how well DSR performs relative to two commonly used benchmark methods, the Emergency Severity Index (ESI) and the Charlson Comorbidity Index (CCI); (4) to what extent DSR provides predictive information beyond ESI, CCI, or their linear combination, i.e., whether ESI and CCI should be used alone or in combination with DSR; and (5) to what extent ESI, CCI, or their linear combination provide predictive information beyond DSR alone, i.e., whether DSR should be used alone or in combination with ESI and / or CCI.MethodsProspective observational study between 2013–2015 (analysis in 2018–2020, study team blinded to hypothesis) conducted at a single center. We study an all-comer cohort of 3,960 patients (48% female patients, median age = 51 years, 94% completed 1-year follow-up). We looked at two primary outcomes (acute morbidity (Bingisser et al., 2017; Weigel et al., 2017) and all-cause 1- year mortality) and three secondary outcomes (in-hospital mortality, hospitalization and transfer to ICU). We assessed the predictive power (i.e., resolution, measured as the Area under the ROC Curve, AUC) of the scores and, using logistic regression, their linear combinations.FindingsCompared to patients without W|F (n = 3,227), patients with W|F (n = 733) showed higher prevalences for all five outcomes, reported more symptoms across both genders, and received higher DSRs (median = 4; interquartile range (IQR) = 3–6 vs. median = 3; IQR = 2–5). DSR predicted all five outcomes well above chance (i.e., AUCs > ~0.70), similarly well for both patients with and without W|F, and as good as or better than ESI and CCI in patients with and without W|F (except for 1-year mortality where CCI performs better). For acute morbidity, hospitalization, and transfer to ICU there is clear evidence that adding DSR to ESI and/or CCI improves predictions for both patient groups; for 1-year mortality and in-hospital mortality this holds for most, but not all comparisons. Adding ESI and/or CCI to DSR generally did not improve performance or even decreased it.ConclusionsThe use of physicians’ disease severity rating has never been investigated in patients with generalized weakness and fatigue. We show that physicians’ prediction of acute morbidity, mortality, hospitalization, and transfer to ICU through their DSR is also accurate in these patients. Across all patients, DSR is less predictive of acute morbidity for female than male patients, however. Future research should investigate how emergency physicians judge their patients’ clinical state at triage and how this can be improved and used in simple decision aids.

An experience-based contrast effect when relying on a decision aid

The present study investigates experience-based contrast effect as a factor that affects users’ decision to rely on decision support systems or not. Two types of experience-based contrast effects were evaluated: “hands-on” and “hard first, simple second.” In the first study, testing “hands-on” contrast, we examined its effect by giving users experience with a task before introducing them to a hard-to-use decision aid to carry out the same task. In the second study, examining “hard first, simple second” contrast, the effect was evaluated by introducing users first to a hard-to-use decision aid and thereafter to a simple decision aid. In both studies, participants took part in two successive sessions in a simulation-based supply chain game. Results demonstrated that both types of contrasts reduced participants’ reliance on the decision aids. Hence, when encouraging users to rely on a decision aid, one should consider the experience-based contrast effects and use them carefully. The implications from this work can contribute to our understanding of the role of experience-based contrast effect when relying on a decision aid.

Detection of COVID-19 Infection from Routine Blood Exams with Machine Learning: A Feasibility Study.

The COVID-19 pandemia due to the SARS-CoV-2 coronavirus, in its first 4 months since its outbreak, has to date reached more than 200 countries worldwide with more than 2 million confirmed cases (probably a much higher number of infected), and almost 200,000 deaths. Amplification of viral RNA by (real time) reverse transcription polymerase chain reaction (rRT-PCR) is the current gold standard test for confirmation of infection, although it presents known shortcomings: long turnaround times (3-4 hours to generate results), potential shortage of reagents, false-negative rates as large as 15-20%, the need for certified laboratories, expensive equipment and trained personnel. Thus there is a need for alternative, faster, less expensive and more accessible tests. We developed two machine learning classification models using hematochemical values from routine blood exams (namely: white blood cells counts, and the platelets, CRP, AST, ALT, GGT, ALP, LDH plasma levels) drawn from 279 patients who, after being admitted to the San Raffaele Hospital (Milan, Italy) emergency-room with COVID-19 symptoms, were screened with the rRT-PCR test performed on respiratory tract specimens. Of these patients, 177 resulted positive, whereas 102 received a negative response. We have developed two machine learning models, to discriminate between patients who are either positive or negative to the SARS-CoV-2: their accuracy ranges between 82% and 86%, and sensitivity between 92% e 95%, so comparably well with respect to the gold standard. We also developed an interpretable Decision Tree model as a simple decision aid for clinician interpreting blood tests (even off-line) for COVID-19 suspect cases. This study demonstrated the feasibility and clinical soundness of using blood tests analysis and machine learning as an alternative to rRT-PCR for identifying COVID-19 positive patients. This is especially useful in those countries, like developing ones, suffering from shortages of rRT-PCR reagents and specialized laboratories. We made available a Web-based tool for clinical reference and evaluation (This tool is available at https://covid19-blood-ml.herokuapp.com/).

Tactical crop management for improved productivity in winter-dominant rainfall regions: a review

This study reviews published information on the tactical management decisions needed to maximise economic grain yield in winter-dominant rainfall regions of the Mediterranean type. Tactical decisions are defined as those relating to the period from immediately before sowing to harvest. Tactical management is the principal means by which farmers respond to changing environmental and short-term economic conditions as the season progresses. The review considers published evidence that underpins these decisions and relates to cereal crops (wheat, barley and oats), pulse crops (field pea, faba bean, chickpea and narrow-leaved lupin) and canola. The criteria used to guide management decisions during the season involve soil and tissue tests for nutrients, knowledge of weed numbers and resistance status in the current and previous seasons, weather conditions that favour disease development, and knowledge of thresholds and biology of insect pests that may warrant control measures. All of these decisions can be related to the timing of the opening rains and the length of the growing season; the crop, pasture or weeds present in the previous two seasons; the presence of pest- and disease-bearing crop residues; and the type of tillage in use. Most of these indicators require further refinement through research across environments, soil types, crop types and production systems. The likely interactions between tactical or short-term management decisions, longer term or strategic decisions, and genetic factors are discussed. The prevalent use of chemicals in the management of biotic factors that can impact the crops is noted, as is progress towards various systems of ‘integrated’ management of these threats to crop production. Most tactical decisions in rainfed cropping systems appear to be supported by adequate evidence, although some decisions are still based on practical experience and observations. Application of tactical management practices together with strategic management and use of improved genotypes provides the possibility of achieving rainfall-limited potential grain yield at a regional scale. The papers reviewed have been selected partly on the basis that the experimental treatments achieved the estimated potential grain yield. Where the potential grain yields are not being achieved in commercial crops, it remains unclear whether this is due to inadequate adoption of existing information or inadequate research to identify and address the underlying causes. We highlight the need to devise a simple decision aid to assist farmers and their advisers to respond to the variable seasonal conditions evident since the turn of the Century.

Decision aid for early identification of acute underlying illness in emergency department patients with atrial fibrillation or flutter.

Emergency department (ED) patients with atrial fibrillation or flutter (AFF) with underlying occult condition such as sepsis or heart failure, and who are managed with rate or rhythm control, have poor prognoses. Such conditions may not be easy to identify early in the ED evaluation when critical treatment decisions are made. We sought to develop a simple decision aid to quickly identify undifferentiated ED AFF patients who are at high risk of acute underlying illness. We collected consecutive ED patients with electrocardiogram-proven AFF over a 1-year period and performed a chart review to ascertain demographics, comorbidities, and investigations. The primary outcome was having an acute underlying illness according to prespecified criteria. We used logistic regression to identify factors associated with the primary outcome, and developed criteria to identify those with an underlying illness at presentation. Of 1,083 consecutive undifferentiated ED AFF patients, 400 (36.9%) had an acute underlying illness; they were older with more comorbidities. Modeling demonstrated that three predictors (ambulance arrival; chief complaint of chest pain, dyspnea, or weakness; CHA2DS2-VASc score greater than 2) identified 93% of patients with acute underlying illness (95% confidence interval [CI], 91-96%) with 54% (95% CI, 50-58%) specificity. The decision aid missed 28 patients; (7.0%) simple blood tests and chest radiography identified all within an hour of presentation. In ED patients with undifferentiated AFF, this simple predictive model rapidly differentiates patients at risk of acute underlying illness, who will likely merit investigations before AFF-specific therapy.

Effects of Shared Decision Making on Opioid Prescribing After Hysterectomy.

To evaluate the effects of shared decision making using a simple decision aid for opioid prescribing after hysterectomy. We conducted a prospective quality initiative study including all patients undergoing hysterectomy for benign, nonobstetric indications between March 1, 2018, and July 31, 2018, at our academic institution. Using a visual decision aid, patients received uniform education regarding postoperative pain management. They were then educated on the department's guidelines regarding the maximum number of tablets recommended per prescription and the mean number of opioid tablets used by a similar cohort of patients in a previously published study at our institution. Patients were then asked to choose their desired number of tablets to receive on discharge. Structured telephone interviews were conducted 14 days after surgery. The primary outcome was total opioids prescribed before compared with after implementation of the decision aid. Secondary outcomes included opioid consumption, patient satisfaction, and refill requests after intervention implementation. Of 170 eligible patients, 159 (93.5%) used the decision aid (one patient who used the decision aid was subsequently excluded from the analysis owing to significant perioperative complications), including 110 (69.6%) laparoscopic, 40 (25.3%) vaginal, and eight (5.3%) abdominal hysterectomies. Telephone surveys were completed for 89.2% (n=141) of participants. Student's t-test showed that patients who participated in the decision aid (post-decision aid cohort) were discharged with significantly fewer oral morphine equivalents than patients who underwent hysterectomy before implementation of the decision aid (pre-decision aid cohort) (92±35 vs 160±81, P<.01), with no significant change in the number of requested refills (9.5% [n=15] vs 5.7% [n=14], P=.15). In the post-decision aid cohort, 76.6% of patients (n=121) chose fewer tablets than the guideline-allotted maximum. Approximately 76% of patients (n=102) reported having leftover tablets. This quality improvement initiative illustrates that a simple decision aid can result in a significant decrease in opioid prescribing without compromising patient satisfaction or postoperative pain management.

Developing and evaluating an intervention to improve care and reduce costs of rabies postexposure therapy: an observational quality improvement initiative in selected vaccination units in Sri Lanka.

Exposure to the rabies virus is fatal unless a patient is treated with a timely, accurate and complete administration of postexposure prophylaxis (PEP). The level of adherence to PEP guidelines by health service providers is therefore critical in providing high-quality care as well as preventing unnecessary costs. We developed a simple user-friendly decision aid based on Sri Lankan national guidelines for the administration of PEP and trialed it over a 5-month period in three study settings. Pre and post levels of adherence to the national guidelines by service providers was measured in each setting. Changes to per patient cost for rabies medications and hospital admissions were also collected. A significant improvement in adherence to the guidelines was observed in two settings with a nonsignificant improvement observed in the third setting. We estimated a total cost saving of LKR 158 476 across the three sites, comprising LKR 14 418 in admissions cost savings and LKR 144 058 in medication savings. We conclude that the development of a decision aid for the administration of PEP is likely to be an effective and cost-saving intervention in the Sri Lankan setting. Further research is required to inform the generalizability of our findings.

Decision aids for people facing health treatment or screening decisions.

Decision aids are interventions that support patients by making their decisions explicit, providing information about options and associated benefits/harms, and helping clarify congruence between decisions and personal values. To assess the effects of decision aids in people facing treatment or screening decisions. Updated search (2012 to April 2015) in CENTRAL; MEDLINE; Embase; PsycINFO; and grey literature; includes CINAHL to September 2008. We included published randomized controlled trials comparing decision aids to usual care and/or alternative interventions. For this update, we excluded studies comparing detailed versus simple decision aids. Two reviewers independently screened citations for inclusion, extracted data, and assessed risk of bias. Primary outcomes, based on the International Patient Decision Aid Standards (IPDAS), were attributes related to the choice made and the decision-making process.Secondary outcomes were behavioural, health, and health system effects.We pooled results using mean differences (MDs) and risk ratios (RRs), applying a random-effects model. We conducted a subgroup analysis of studies that used the patient decision aid to prepare for the consultation and of those that used it in the consultation. We used GRADE to assess the strength of the evidence. We included 105 studies involving 31,043 participants. This update added 18 studies and removed 28 previously included studies comparing detailed versus simple decision aids. During the 'Risk of bias' assessment, we rated two items (selective reporting and blinding of participants/personnel) as mostly unclear due to inadequate reporting. Twelve of 105 studies were at high risk of bias.With regard to the attributes of the choice made, decision aids increased participants' knowledge (MD 13.27/100; 95% confidence interval (CI) 11.32 to 15.23; 52 studies; N = 13,316; high-quality evidence), accuracy of risk perceptions (RR 2.10; 95% CI 1.66 to 2.66; 17 studies; N = 5096; moderate-quality evidence), and congruency between informed values and care choices (RR 2.06; 95% CI 1.46 to 2.91; 10 studies; N = 4626; low-quality evidence) compared to usual care.Regarding attributes related to the decision-making process and compared to usual care, decision aids decreased decisional conflict related to feeling uninformed (MD -9.28/100; 95% CI -12.20 to -6.36; 27 studies; N = 5707; high-quality evidence), indecision about personal values (MD -8.81/100; 95% CI -11.99 to -5.63; 23 studies; N = 5068; high-quality evidence), and the proportion of people who were passive in decision making (RR 0.68; 95% CI 0.55 to 0.83; 16 studies; N = 3180; moderate-quality evidence).Decision aids reduced the proportion of undecided participants and appeared to have a positive effect on patient-clinician communication. Moreover, those exposed to a decision aid were either equally or more satisfied with their decision, the decision-making process, and/or the preparation for decision making compared to usual care.Decision aids also reduced the number of people choosing major elective invasive surgery in favour of more conservative options (RR 0.86; 95% CI 0.75 to 1.00; 18 studies; N = 3844), but this reduction reached statistical significance only after removing the study on prophylactic mastectomy for breast cancer gene carriers (RR 0.84; 95% CI 0.73 to 0.97; 17 studies; N = 3108). Compared to usual care, decision aids reduced the number of people choosing prostate-specific antigen screening (RR 0.88; 95% CI 0.80 to 0.98; 10 studies; N = 3996) and increased those choosing to start new medications for diabetes (RR 1.65; 95% CI 1.06 to 2.56; 4 studies; N = 447). For other testing and screening choices, mostly there were no differences between decision aids and usual care.The median effect of decision aids on length of consultation was 2.6 minutes longer (24 versus 21; 7.5% increase). The costs of the decision aid group were lower in two studies and similar to usual care in four studies. People receiving decision aids do not appear to differ from those receiving usual care in terms of anxiety, general health outcomes, and condition-specific health outcomes. Studies did not report adverse events associated with the use of decision aids.In subgroup analysis, we compared results for decision aids used in preparation for the consultation versus during the consultation, finding similar improvements in pooled analysis for knowledge and accurate risk perception. For other outcomes, we could not conduct formal subgroup analyses because there were too few studies in each subgroup. Compared to usual care across a wide variety of decision contexts, people exposed to decision aids feel more knowledgeable, better informed, and clearer about their values, and they probably have a more active role in decision making and more accurate risk perceptions. There is growing evidence that decision aids may improve values-congruent choices. There are no adverse effects on health outcomes or satisfaction. New for this updated is evidence indicating improved knowledge and accurate risk perceptions when decision aids are used either within or in preparation for the consultation. Further research is needed on the effects on adherence with the chosen option, cost-effectiveness, and use with lower literacy populations.

Impact of a Prostate Specific Antigen Screening Decision Aid on Clinic Function

IntroductionDecision aids for prostate cancer screening can increase knowledge and shared decision making, but remain underused due to cost and time constraints that disrupt clinic flow. We examined the impact of a simple prostate specific antigen screening decision aid distribution strategy on clinic flow as well as shared decision making in a diverse, urban primary care clinic. MethodsMen 50 to 75 years old viewed the decision aid while waiting for physicians. Participants and physicians completed questionnaires evaluating the shared decision making process. Focus groups were conducted with clinic staff and physicians to evaluate the impact on clinic operations. ResultsOverall 50% of men discussed prostate specific antigen screening and 85% reported the decision aid made decision making easier. Participants reported an average of 12.9 minutes reading the decision aid, with high decision satisfaction and low decisional conflict. Physicians reported an average of 5.2 minutes discussing prostate specific antigen screening. Clinic staff reported increased enthusiasm for the process after adjustments were made in response to concerns including time, as well as lack of knowledge about the decision aid subject matter and involvement in the process. Physician reported barriers included ambivalence about prostate specific antigen screening. ConclusionsA prostate specific antigen screening decision aid, requiring few resources, can be implemented with broad involvement of clinic staff and minimal disruption to clinic flow in an urban primary care clinic, and may facilitate shared decision making.

Baux Cutoff Points Predict Geriatric Burn Outcomes

Baux Cutoff Points Predict Geriatric Burn Outcomes

Ethical Information Transparency and Sexually Transmitted Infections.

Shared decision making is intended to help protect patient autonomy while satisfying the demands of beneficence. In shared decision making, information is shared between health care professional and patient. The sharing of information presents new and practical problems about how much information to share and how transparent that information should be. Sharing information also allows for subtle paternalistic strategies to be employed to "nudge" the patient in a desired direction. These problems are illustrated in two experiments. Experiment 1 (N = 146) suggested that positively framed messages increased the strength of judgments about whether a patient with HIV should designate a surrogate compared to a negatively framed message. A simple decision aid did not reliably reduce this effect. Experiment 2 (N = 492) replicated these effects. In addition, Experiment 2 suggested that providing some additional information (e.g., about surrogate decision making accuracy) can reduce tendencies to think that one with AIDS should designate a surrogate. These results indicate that in some circumstances, nudges (e.g., framing) influence judgments in ways that non-nudging interventions (e.g., simple graphs) do not. While non-nudging interventions are generally preferable, careful thought is required for determining the relative benefits and costs associated with information transparency and persuasion.

Simple Decision Aids and Consumer Decision Making

To help consumers deal with increasing amounts of information, many online retailers offer simple decision aids, such as the ability to sort on a particular attribute or eliminate undesired alternatives. The authors propose that consumers use simple decision aids as substitutes for cognitive effort, potentially with adverse consequences for decision making. An experimental study shows that providing unrestricted sorting increases decision quality only when choice conflict is low; beyond a certain point, greater use of the decision aid is associated with declines in decision quality. A second study shows that that allowing consumers to sort alternatives only one time enhances decision quality and, when choice conflict is high, reduces decision effort. A third study shows that providing elimination as well as sorting tools helps mitigate the negative effects of simple decision aids. Although the availability of sorting alone hurts decision quality when choice conflict is high, decision quality under choice conflict is improved when both sorting and elimination tools are provided. Implications for retail practice are discussed.

Farmers' knowledge and perceptions of the stunting disease of Napier grass in Western Kenya

Production of Napier grass, Pennisetum purpureum, the most important livestock fodder in Western Kenya, is severely constrained by Napier stunt (Ns) disease. Understanding farmers' knowledge, perceptions and practices is a prerequisite to establishing an effective disease management approach. Using a random sample of 150 farmers drawn from Bungoma, Busia and Teso districts of Western Kenya, this study sought to: (i) assess farmers' perceptions and knowledge of Ns disease, including its effects on the smallholder dairy industry; (ii) record farmers' current practices in managing Ns disease; and (iii) identify Ns disease management challenges and intervention opportunities in order to develop an efficient integrated disease management approach. The majority (86·7%) of the farmers were aware of Ns disease and observed that it was spreading rapidly in the region, which was perfectly predicted by farmers' access to agricultural information (marginal effect = 0·164), indicating a need for extension platforms for knowledge sharing among the industry stakeholders. The disease had affected Napier grass yields so most farmers could not feed their livestock on the amounts they produced, and they were buying Napier grass. Those who relied on income from selling Napier grass received less due to loss in productivity. Milk production had reduced by over 35%. The cause of the disease was unknown to the farmers, with no effective disease management strategy available to them. An integrated disease management approach needs to be developed to fit within the mixed farming systems, supported by simple decision aids.

IMPROVING END OF LIFE CARE FOR PATIENTS WITH COPD AN EVALUATION OF A SERVICE INNOVATION USING THE “WOULD YOU BE SURPRISED? QUESTION

BackgroundThe National End of Life Strategy initiative “would you be surprised if this person died within the next 6–12 months?”1 formed basis of a protocol to identify COPD patients with...

Borrow Less Tomorrow: Behavioral Approaches to Debt Reduction

Mounting evidence suggests that behavioral factors depress wealth accumulation. Although much research and policy focuses on asset accumulation, for many households debt decumulation is more efficient. Yet the mass market for debt reduction services is thin. So we develop and pilot test Borrow Less Tomorrow (BoLT), a behavioral approach to debt reduction that combines a simple decision aid, social commitment, and reminders. Results from a sample of free tax-preparation clients with eligible debt in Tulsa (N=465) indicate strong demand for debt reduction: 41% of those offered BoLT used it to make a plan to accelerate debt repayment. Using random assignment to BoLT offers, we find weak evidence that the BoLT package offered reduces credit card debt.