Clinical decision models

Simple, low cost, and high value additions to the clinical workflow.

In the December 2, 2022 post, I presented briefly described a new strategy to improve the quality of clinical decisions. It is divided into two parts. The first addresses the clinical decision making process and the second deals with how to integrate an improved decision making process into routine clinical practice.

The proposed strategy for improving the decision making process is based on the Decision Quality Chain, developed by the Strategic Decisions Group. [1,2] The first steps in the chain are:

- Helpful frame: What am I really deciding?

- Create Alternatives: What can I do?

- Clear Values: What do I want?

- Useful Information: What do I need to know?

Taken together, these are the elements of a decision model, a fundamental component of decision analysis and other formal decision making methods. Decision models are essentially a map of the decision. Just as using a geographical map helps people get from point A to point B, using a decision map/model helps ensure that everyone involved understands what is being decided and what factors will be included in making a decision. In addition, they facilitate communication among decision makers, identify what information is needed, and document the decision making process.

There are several ways to construct a decision model/map. For most clinical decisions, I believe a basic hierarchy, as illustrated in the figure below, is the most useful one to start with. This is because it is easy to understand, compact, contains an explicit statement of the goal of the decision, clearly identifies the values that will be used to compare the alternatives, and is in a format that can be easily shared with patients, included in the medical record, and re-visited in the future if desired.

To illustrate, imagine a patient called Anna.

Anna runs a popular artisan bread bakery. She has recently developed an illness called Hendassa Disease that is causing symptoms severe enough to make it difficult for her to carry out her usual duties. Although Hendassa Disease usually progresses over time, it also can remit spontaneously. ( Hendassa Disease is not a real disease. I invented it for this illustration.)

When her illness was first diagnosed, Anna and her health care provider, Dr. Woodland, decided to wait to see if the symptoms persisted or progressed before starting an active treatment. Now that the symptoms have continued and are getting worse, Anna decides to revisit Dr. Woodland to discuss starting an active treatment regimen.

Currently, four drugs are available to treat Hendassa Disease: Drug A, Drug B, Drug C, and Drug D:

• Drug A has been used for many years. It effectively controls the disease in about 85% of patients, causes few side effects and is inexpensive. It is taken orally twice daily.

• Drug B has been available for about 5 years. It is slightly more effective than Drug A but has a higher rate of side effects. It is not available generically but the brand name is on Anna’s insurance carrier’s preferred drug list. It is taken orally once a day.

• Drug C has also been available for about 5 years. It is less effective than either Drug A or Drug B and has a higher rate of side effects. It is also more expensive since it is not a “preferred” drug in Anna’s insurance company formulary. It is taken orally twice daily.

• Drug D is a new drug released during the past year. It effectively controls Hendassa Disease in about 85% of patients. However, it has been associated with a higher rate of side effects than either Drug A or B and is more expensive. It is taken by injection once a month.

Current treatment guidelines indicate that there is enough evidence available to make all four drugs acceptable treatments and recommend that decisions about which drug to use should be made through an informed, patient-centered shared decision making process.

Anna and Dr. Woodland define the elements of this decision as follows:

• Goal: Since a decision to start active treatment has already been made, the decision goal is to pick the best drug for Anna’s initial treatment.

• Options: Drug A, Drug B, Drug C, Drug D

• Decision Factors: Effectiveness, Risk of side effects, Out of pocket costs, Ease of administration

Based on this list of decision elements they create the following decision model.

Note that it is not necessary to create a decision model from scratch every time. For common clinical decisions, generic decision maps could be created and then adapted to meet the needs of different patients and clinical circumstances.

Musings

Being clear about the decision that needs to be made is an essential first step in informed patient care and good decision making. The use of a simple hierarchical model is an effective way to ensure both patients and providers understand the choice they are facing and how they will make the decision. This step takes little time relative to the benefits gained, particularly if a prepared map is used as a starting point and adjusted as needed.

Most of the time, discussions about shared decision making focus on the interaction between provider and patient. However, other layers of the health care system - insurers, guideline panels, and others - are also involved in many cases. The use of an explicit decision model would make it possible to share decisions vertically throughout the health care system as well as horizontally at the clinical level. For example, I see no reason why a clinical guideline panel could not create a basic decision map that is then shared with clinicians and modified as needed for individual patients.

I can imagine that it also would be possible to create a “values/preferences” profile for each patient, based on the list of factors they think are important in making health care decisions. Anna’s list is likely to be appropriate for many situations and people. Once made, it would serve as a logical starting place for placing a new decision into a familiar context.

References

1. Decision Quality Defined | Strategic Decisions Group [Internet]. SDG. [cited 2022 Dec 1]. Available from: https://sdg.com/thought-leadership/decision-quality-defined/

2. Decision Quality: Value Creation from Better Business Decisions | Wiley [Internet]. Wiley.com. [cited 2022 Dec 1]. Available from: https://www.wiley.com/en-us/Decision+Quality%3A+Value+Creation+from+Better+Business+Decisions-p-9781119144670