Transforming clinical practice guidelines and clinical pathways into fast-and-frugal decision trees to improve clinical care strategies
Transforming clinical practice guidelines and clinical pathways into fast-and-frugal decision trees to improve clinical care strategies
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DOI：
10.1111/jep.12895
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发表时间：
2018-10-01
影响因子：
2.4
通讯作者：
Dale, William
中科院分区：
文献类型：
--
作者：
Djulbegovic, Benjamin;Hozo, Iztok;Dale, William
BackgroundContemporary交付的卫生保健是不适当的，在许多方面，主要是由于次优Q5决策。一个典型的方法，以提高从业者的决策是制定循证临床实践指南（CPG）的指南小组，谁被指示使用他们的判断，以获得实践建议。然而，机制制定的指导方针的判断仍然是一个黑箱operationa过程与定义的输入和输出，但没有足够的知识，其内部workings.MethodsIncreased明确性和透明度的过程中，可以实现通过实施CPG的临床路径（CP）（也被称为临床算法或流程图）。然而，由此得出的临床建议通常是临时的，由专家在无理论的环境中开发。由于任何建议可以是正确的（真阳性或阴性），或错误的（假阳性或阴性），缺乏理论结构排除了定量评估的管理策略建议的CPGs/CPs.ResultsTo实现的CPGs/CPs的全部潜力，他们需要放在更坚实的理论基础。我们相信，这种潜力可以通过在决策的启发式理论中转换CPG/CP来最好地实现，通常实现为快速和节俭（FFT）决策树。这是可能的，因为FFT启发式决策策略可以连接到信号检测理论，证据积累理论，和阈值模型的决策，这反过来，允许定量分析的准确性，临床管理strategies.ConclusionsFast-and-frugal提供了一个简单而透明的，但坚实而强大的，方法框架连接决策科学的临床护理，CPG/CP和患者结局之间急需缺失的环节。因此，我们主张所有指南小组都以CP的形式表达他们的建议，而CP又应该转换为FFT来指导临床护理。
BackgroundContemporary delivery of health care is inappropriate in many ways, largely due to suboptimal Q5 decision-making. A typical approach to improve practitioners' decision-making is to develop evidence-based clinical practice guidelines (CPG) by guidelines panels, who are instructed to use their judgments to derive practice recommendations. However, mechanisms for the formulation of guideline judgments remains a black-box operationa process with defined inputs and outputs but without sufficient knowledge of its internal workings.MethodsIncreased explicitness and transparency in the process can be achieved by implementing CPG as clinical pathways (CPs) (also known as clinical algorithms or flow-charts). However, clinical recommendations thus derived are typically ad hoc and developed by experts in a theory-free environment. As any recommendation can be right (true positive or negative), or wrong (false positive or negative), the lack of theoretical structure precludes the quantitative assessment of the management strategies recommended by CPGs/CPs.ResultsTo realize the full potential of CPGs/CPs, they need to be placed on more solid theoretical grounds. We believe this potential can be best realized by converting CPGs/CPs within the heuristic theory of decision-making, often implemented as fast-and-frugal (FFT) decision trees. This is possible because FFT heuristic strategy of decision-making can be linked to signal detection theory, evidence accumulation theory, and a threshold model of decision-making, which, in turn, allows quantitative analysis of the accuracy of clinical management strategies.ConclusionsFast-and-frugal provides a simple and transparent, yet solid and robust, methodological framework connecting decision science to clinical care, a sorely needed missing link between CPGs/CPs and patient outcomes. We therefore advocate that all guidelines panels express their recommendations as CPs, which in turn should be converted into FFTs to guide clinical care.