BMC Med Inform Decis Mak - Extensions to regret-based decision curve analysis: an application to hospice referral for terminal patients.

Tópicos

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Resumo

CKGROUND: Despite the well documented advantages of hospice care, most terminally ill patients do not reap the maximum benefit from hospice services, with the majority of them receiving hospice care either prematurely or delayed. Decision systems to improve the hospice referral process are sorely needed.METHODS: We present a novel theoretical framework that is based on well-established methodologies of prognostication and decision analysis to assist with the hospice referral process for terminally ill patients. We linked the SUPPORT statistical model, widely regarded as one of the most accurate models for prognostication of terminally ill patients, with the recently developed regret based decision curve analysis (regret DCA). We extend the regret DCA methodology to consider harms associated with the prognostication test as well as harms and effects of the management strategies. In order to enable patients and physicians in making these complex decisions in real-time, we developed an easily accessible web-based decision support system available at the point of care.RESULTS: The web-based decision support system facilitates the hospice referral process in three steps. First, the patient or surrogate is interviewed to elicit his/her personal preferences regarding the continuation of life-sustaining treatment vs. palliative care. Then, regret DCA is employed to identify the best strategy for the particular patient in terms of threshold probability at which he/she is indifferent between continuation of treatment and of hospice referral. Finally, if necessary, the probabilities of survival and death for the particular patient are computed based on the SUPPORT prognostication model and contrasted with the patient's threshold probability. The web-based design of the CDSS enables patients, physicians, and family members to participate in the decision process from anywhere internet access is available.CONCLUSIONS: We present a theoretical framework to facilitate the hospice referral process. Further rigorous clinical evaluation including testing in a prospective randomized controlled trial is required and planned.

Resumo Limpo

ckground despit well document advantag hospic care termin ill patient reap maximum benefit hospic servic major receiv hospic care either prematur delay decis system improv hospic referr process sore neededmethod present novel theoret framework base wellestablish methodolog prognost decis analysi assist hospic referr process termin ill patient link support statist model wide regard one accur model prognost termin ill patient recent develop regret base decis curv analysi regret dca extend regret dca methodolog consid harm associ prognost test well harm effect manag strategi order enabl patient physician make complex decis realtim develop easili access webbas decis support system avail point careresult webbas decis support system facilit hospic referr process three step first patient surrog interview elicit hisher person prefer regard continu lifesustain treatment vs palliat care regret dca employ identifi best strategi particular patient term threshold probabl hesh indiffer continu treatment hospic referr final necessari probabl surviv death particular patient comput base support prognost model contrast patient threshold probabl webbas design cdss enabl patient physician famili member particip decis process anywher internet access availableconclus present theoret framework facilit hospic referr process rigor clinic evalu includ test prospect random control trial requir plan

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