Evaluation of Computerized Decision Support for Managing Lung Nodules

描述(由申请人提供)：在以前的研究中，我们小组的成员开发了炼金术士，这是一个计算机化的决策支持系统，根据决策分析模型生成针对患者和特定地点的建议，用于患者管理。随后，我们开发了炼金术师-SPN，这是一个基于网络的决策支持系统，用于管理孤立性肺结节(SPN)患者，将严格开发的决策分析模型与现有的炼金术师计算机决策支持体系相结合。同时，我们对决策模型进行了统计验证，结果表明，炼金术师-SPN的决策支持有可能改善经质量调整的生存率，降低成本，并减少良性结节患者不必要手术的频率，以及恶性结节患者不适当的“警觉等待”。肺结节的管理是计算机决策支持的一个非常有吸引力的目标；它是一个常见的问题，存在多种可能的管理策略，而最优的管理方法取决于预试概率、手术并发症的风险、患者的喜好等因素。在我们竞争续签申请的第二次修订中，我们寻求资金来继续我们对炼金术士-SPN的系统评估。具体地说，我们根据以前应用程序评审员的有用反馈修改了我们的目标和方法。修订后的建议包括三个具体目标：(1)进行严格的可用性测试和同行审查过程，使能够设计和改进高度响应潜在用户需求的决策支持系统；(2)通过进行随机对照试验，比较医生在接触炼金师-SPN或静态流程图算法后对临床阶段的管理，确定炼金师-SPN是否有潜力在理想化的实验室条件下改善肺结节患者的预后；(3)通过将决策支持系统集成到SPN管理的临床工作流程中，在两个医疗保健环境中实施炼金师-SPN，并在这些环境中进行炼金师-SPN实施前后的研究，以确定临床医生是否会使用决策支持系统并遵守其建议。通过实现这些目标，我们不仅将评估用于管理肺结节的高度创新的计算机化决策支持系统的性能，还将根据实验室和临床环境中专家和执业临床医生的反馈来改进该系统的性能。最终，我们相信我们的炼金术师SPN的计算机决策支持方法有可能改善肺结节患者的管理，并可能广泛适用于胸部肿瘤学和临床医学的其他具有挑战性的问题。公共卫生相关性这项研究旨在评估一种新的、基于计算机的系统，以改善对孤立性肺结节(或“肺部斑点”)患者的管理，孤立性肺结节有时代表一种可治愈的肺癌形式。通过评估并最终实施该系统，我们的目标是减少非癌症肺结节患者进行不必要手术的频率，并减少可能导致癌症结节患者错过治愈机会的延迟手术的数量。

DESCRIPTION (provided by applicant): In previous research, members of our group developed ALCHEMIST, a computerized decision support system that generates patient- and site-specific recommendations for patient management based on decision- analytic models. Subsequently, we developed ALCHEMIST-SPN, a web-based decision support system for managing patients with solitary pulmonary nodules (SPN), by linking a rigorously developed decision analytic model with the existing ALCHEMIST architecture for computer-based decision support. Concurrently, we performed a statistical validation of the decision model, and showed that decision support with ALCHEMIST-SPN has the potential to improve quality-adjusted survival, reduce cost, and reduce the frequency of unnecessary surgery in patients with benign nodules and inappropriate "watchful waiting" in patients with malignant nodules. Management of lung nodules is a very attractive target for computer-based decision support; it is a common problem, multiple possible management strategies exist, and the optimal management approach depends on pre-test probability, the risk of surgical complications, patient preferences, and other factors. In this second revision of our competing renewal application, we seek funding to continue our systematic evaluation of ALCHEMIST-SPN. Specifically, we have revised our aims and methods based on helpful feedback from reviewers of our previous applications. The revised proposal includes three specific aims: (1) to conduct a rigorous process of usability testing and peer review, to enable design and refinement of a decision support system that is highly responsive to the needs of potential users; (2) to determine whether ALCHEMIST-SPN has the potential to improve outcomes in patients with lung nodules under idealized laboratory conditions, by conducting a randomized, controlled trial that compares management of clinical vignettes by physicians following exposure to either ALCHEMIST-SPN or a static flow-chart algorithm; (3) to implement ALCHEMIST-SPN in two health care settings, by integrating the decision support system into the clinical workflow of SPN management, and to conduct a "before and after" implementation study of ALCHEMIST-SPN in these settings to determine whether clinicians will use the decision support system and adhere to its recommendations. By accomplishing these aims, we will not only evaluate the performance of a highly innovative computerized decision support system for managing lung nodules, but also improve the system's performance based on feedback from both experts and practicing clinicians in laboratory and clinical settings. Ultimately, we believe that our approach to computerized decision support with ALCHEMIST-SPN has the potential to improve management in patients with lung nodules, and may be broadly applicable to other challenging problems in thoracic oncology and clinical medicine. PUBLIC HEALTH RELEVANCE This research aims to evaluate a novel, computer-based system for improving management in patients with solitary pulmonary nodules (or "spots on the lung"), which sometimes represent a curable form of lung cancer. By evaluating and eventually implementing the system, we aim to reduce the frequency of unnecessary surgery in patients with non-cancerous lung nodules, and reduce the number of delayed surgeries that may lead to missed opportunities for cure in patients with cancerous nodules.