A conditional model of evidence‐based decision making

Abstract

Rationale-Efforts to describe how individual treatment decisions are informed by systematic knowledge have been hindered by a standard that gauges the quality of clinical decisions by their adherence to guidelines and evidence-based practices. This paper tests a new contextual standard that gauges the incorporation of knowledge into practice and develops a model of evidence-based decision making.Aims and objectives-Previous work found that the forecasted outcome of a treatment guideline exerts a highly significant influence on how it is used in making decisions. This study proposed that forecasted outcomes affect the recognition of a treatment scenario, and this recognition triggers distinct contextual decision strategies.Method-N=21 volunteers from a psychiatric residency program responded to 64 case vignettes, 16 in each of four treatment scenarios. The vignettes represented a fully balanced within-subjects design that included guideline switching criteria and patient-specific factors. For each vignette, participants indicated whether they endorsed the guideline's recommendation.Results-Clinicians employed consistent contextual decision strategies in responding to clearly positive or negative forecasts. When forecasts were more ambiguous or risky, their strategies became complex and relatively inconsistent. Conclusion-The results support a three step model of evidence-based decision making, in which clinicians recognize a decision scenario, apply a simple contextual strategy, then if necessary engage a more complex strategy to resolve discrepancies between general guidelines and specific cases. The paper concludes by noting study limitations and discussing implications of the model for future research in clinical and shared decision making, training, and guideline development.

Optimizing clozapine through clinical decision making

“…While the importance of contextualizing treatment decisions has long been noted in schizophrenia guidelines (47, 48) and is regarded an essential element of evidence-based medicine (49)(50)(51), the ability of clinicians to perform this task systematically and consistently has largely been presumed rather than explicitly tested. Only a few studies have directly examined contextual decision-making processes (52)(53)(54), and they have explored the influence of clinical and psychosocial factors such as treatment adherence, likelihood of decompensation, stressors and medical complications. No studies to date have examined how clinicians incorporate the patientÕs perspective into a framework that includes general evidence and clinical information.…”

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“…The counting rule has been examined in studies of behavioral decision making 41–46 and clinical decision making 47–49 . The rule is efficient, additive, and noncompensatory.…”

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