Pre-existing dementia is associated with poorer functional outcome after stroke. It is unclear however whether this is due to lack of access to, or inequality in, stroke rehabilitation. This PhD used mixed methods to understand whether pre-existing dementia is a factor considered by clinicians when referring/admitting patients for rehabilitation, when providing rehabilitation interventions, and whether there is a difference in rehabilitation received by patients with and without pre-existing dementia. A background literature review informed the first study, which was a systematic review examining factors influencing clinical decision-making about access to stroke rehabilitation. The systematic review suggested that pre-stroke cognition influenced referrals/admission to rehabilitation, however, no studies examined this specifically. The qualitative study therefore used interviews (n=23) to explore clinicians experiences of decision-making about rehabilitation for patients with pre-existing dementia/cognitive impairments. The findings highlighted that clinicians own knowledge influenced their decision-making, with a common perception that people with pre-existing cognitive impairment lack potential to benefit from rehabilitation. The third study, a prospective cohort study, examined differences in rehabilitation received by patients with and without pre-existing cognitive impairments (n=139). People with pre-existing cognitive impairments received less rehabilitation than those without, particularly physiotherapy and referral to community therapies and more non-patient facing occupational therapy. This PhD identified that people with pre-existing dementia/cognitive impairment receive less rehabilitation when compared to those without. This may be, in part, due to clinicians decision-making about which patients should receive stroke rehabilitation. These findings have multiple clinical implications, particularly around the number of patients in stroke services with undiagnosed pre-existing cognitive impairment. Decisions can become more equitable by ensuring clinicians have access to relevant education, training and skills to work alongside patients with pre-existing dementia/cognitive impairments.

Thesis (Ph.D.)--University of Wollongong, 2008. / Typescript. Includes bibliographical references: leaf 272-295.

CEO competence and development is a continuing concern in the NHS. As a key feature of any CEO leadership role is responsibility for organisationally critical decisions, and there is an increasing recognition of the role context plays in effective leadership behaviour. This study examines the role of contextual intelligence in relation to PCT CEO decision making behaviour. To do this, the research addresses four questions: a) what does the literature say about CEO contextual intelligence? b) what factors do PCT CEOs say they take into account in different decision making contexts? c) what contextual factors do they actually take into account? and d) what impact do the contextual factors have on their decision making behaviour. A systematic literature review resulted in a model of CEO contextual intelligence for CEO decision making. Semi-structured interviews with 24 PCT CEOs in a NHS region about factors influencing their decisions on generic strategies, national policies, regional strategies and local plans revealed a hierarchy among contextual factors applying to different decision strata. Semi-structured interviews and analysis of CEO diaries two months later of the same focal decisions show the real critical factors to be:- national policies themselves, the Strategic Health Authority and the decision making process, for regional strategies; and Top Management Team and structure for local plans. Altogether, the research reveals that the PCT CEO’s decision making context is rationally bounded; the relevant contextual factors differed significantly from the literature derived model; the actual factors in practice differed from what were espoused; choice of factors vary depending on decision trigger strata which links to degrees of CEO autonomy; and macro level factors which were indicated as significant from the systematic review were in fact ignored in practice. A PCT CEO model of contextual intelligence is developed together with a two dimensional model of underlying structures guiding PCT CEO decision making behaviour. The findings have implications for governance structures in the NHS, CEO decision making and senior leader development in ii the NHS in the context of the 2012 Health and Social Care Act. Areas for further research in public sector, NHS and contextual intelligence are also identified.

The decisions made by Mental Health Professionals (MHPs) are of utmost significance for providing the highest quality care to service users. The assessment of risk is one of the pivotal processes that MHPs undertake frequently, as per government policy guidelines, and in order to safeguard patients and the public. Although Risk Assessment Proformas (RAPs) consume a proportion of MHP time and resources, very little research has been undertaken to address factors that might affect their most optimal utilisation in practice. Previous literature suggests that medical decisions, like decision making of other kinds, is fraught with difficulty including being susceptible to the influence of cognitive biases, pre-decisional affect, overconfidence, and subjectively held attitudes towards organisational policies and regulations. Specifically, the presentation of risk information can influence decisions. It has also been suggested that anxiety has the capacity to elicit risk aversive responses, and that overconfidence and negative attitude may lead to complacency in undertaking policy-led responsibilities and produce non-compliance for the same. However, much of what is known about medical decision making has been gleaned from outside of context of mental health. As such, the current programme of research aimed to explore decision making in mental health settings and with a view to raise awareness of the complexity of decision making amongst MHPs. The implementation of quantitative and qualitative techniques (studies 1 and 2) revealed negative attitudes from psychiatrists towards Risk Assessment Proformas (RAPs), which are essentially structured decision making aids. Psychiatrist, compared to other MHPs, spent less time completing RAPs, which may reflect their differing attitudes towards their usefulness, something that was consistently emphasised during in-depth qualitative exploration. It was also found that experience was an additional differentiating factor between MHPs. Relationships between experience and other factors such as anxiety, confidence and complacency were found via conversations with MPHs, experience members of staff being less inclined to provide comprehensive and detailed accounts of service user risk in RAPs. This is problematic since although there is, in the UK, a policy led requirement that RAPs are completed for each service user, it is clear that there are inter-professional variations in how RAPs are being used and this acts to inhibit the best information sharing between all those involved in patient care. Following previous work in the area of cognitive bias and its influence upon general and medical decisions, a clinical vignette was also developed (study 3) to establish whether the presentation of risk information influences psychiatric admission decisions. The current findings supported previous work in that decisions were susceptible to the framing effect. The findings here, and previously in the literature, reveal a necessity for MHPs to be informed of bias in decision making in an attempt to improve objectivity in risk assessment practices. The unearthing of the framing effect also further signals the need for proper use of RAPs, where many MHPs may not be using them to their full potential - i.e. an aid to the systematic consideration of a range of information about a service user. The final part of the thesis (study 4) turned to the piloting of an educational module incorporating content around the factors affecting decision making in an attempt to raise awareness amongst MHPs. The rationale being better awareness of the complexity of decision making may act to enhance decision making processes. Pre and post intervention analyses revealed an improvement of baseline to follow-up knowledge of decision making bias and statistical concepts and this knowledge was maintained to a moderate level at four weeks follow-up. Although individuals maintained their susceptibility to the framing effect, the bias was less prevalent in those who knew of its presence before taking part in the study. Overall the findings give some support to the use of education as an approach to raising awareness about decision making processes in MHPs, although what remains to be seen is whether such education acts to bring about changes in behaviour - for example, different use of RAPs. The PhD programme suggests that MHPs are just as susceptible to cognitive biases, such as the framing effect, as has been demonstrated in both general population and other groups of health practitioners. At the same time, attitudes to RAPs differ depending on exact job role, which psychiatrist being least likely to spend time on their completion and reporting them as a tool for noting decisions reached as opposed to an aid to the process. This acts reduce the quality and quantity of reported information shared with colleagues about a service user. It is possible that MHP behaviour aligns with general attitude-behaviour models, such as the Theory of Planned Behaviour. As such, whilst the current work has demonstrated that educational interventions may act to improve awareness of decision making processes and their influences, further research would benefit from considering if these types of approach affect actual behaviour. For example, improved used of RAPs as decision-aids, reduced susceptibility to framing effects, consciousness around how information is represented in RAPs given knowledge of how the information may be used by others.

Stepped care is designed to provide mental health treatment in the most effective and efficient way. It aims to provide patients with low intensity interventions in the first instance and only move onto high intensity treatments if outcome is not 'successful'. However, there is a paucity of research about how health professionals make decisions about treatment and the experiences of patients within this decision-making process. Using a multi-method approach, this study aimed to explore health professional and patient decision-making in stepped care for anxiety and depression. 24 health professional interviews from three stepped care sites were conducted, which included the completion of an active information search (AIS) think-aloud task. In addition, 14 patients were interviewed about their experiences of decision-making whilst being managed within stepped care model. Qualitative interview data was analysed using the principles of Framework analysis, while some of the data collected in the AIS think-aloud task lent itself to quantitative analysis.This study revealed that three core tensions exist when making decisions within the stepped care model. These are 1. The notion of standardisation of outcomes versus the individual needs of patients; 2. The public health orientation of stepped care versus the therapeutic orientation of health professionals and; 3. The rhetoric about patient choices versus the realities of shared decision-making in a resource-limited system.The complexity of decision-making within the stepped care model was highlighted. The success of stepped care relies on ensuring that there is an adequate workforce to deliver the intended interventions, where this is not present health professionals are faced with difficult decisions and it is clear that those most affected are the less-experienced frontline workers. Scarcity of resources impacts heavily upon the decisions that are made. This can have a substantial impact upon variability in treatment decisions and on the ability to allow for patient choice to be incorporated. Decisions that are made for a patient are influenced by the need to provide them with the treatment that they want (which may not be regarded as what they need within the stepped care model nor necessarily by the health professional) and the capacity of the service. The problem that exists with primary care mental health is that the current demands exceed capacity. Optimal patient care is, in part, traded off by the need to meet the demands of the service. Improving the flexibility of the service may be one solution to the problem and adopting a stratified/stepped care approach might help to resolve some of the tensions and help to relieve some of the capacity issues.

Source: Masters Abstracts International, Volume: 46-05, page: 2674. Adviser: Carl Hacker. Includes bibliographical references.

The increasingly high costs of health care in the U.S. have led the general public to search for different medical approaches. Since the 1990's, the use of Complementary and Alternative Medicine (CAM) has radically increased in the U.S. due to its approach to treat physical, mental, and emotional causes of illness. In 2009, the National Health Statistics reported the impact of CAM in the U.S. health care economy, with population expenditures of $14.8 billion out-of-pocket on natural Medicine and $12.4 billion out-of-pocket on visits to CAM providers as a complement to Western Medicine care. CAM interconnects human functions to reach a balanced state, whereas Western Medicine focuses on specialties and body systems. Both Western Medicine and CAM are unlimited sources of knowledge that follow different approaches but that have the common goal of improving patients' well-being. Identifying relationships between Alternative and Western Medicine can open a completely new approach for health care that can increase understanding of human medical conditions, and facilitate the development of new and more cost-effective treatments. However, the abundance and dissimilarity of CAM and Western Medicine data makes knowledge correlation and management an extremely challenging task. The objective of this research is to design the framework for a knowledge management system to organize, store, and manage the abundant data available for Western Medicine and CAM, and to establish key relationships between the two practices for an effective exploration of ideas and possible solutions for medical diagnosis. Three main challenges in the design of the proposed framework are addressed: data acquisition and modeling; data organization, storage and transfer; and information distribution for further generation and sharing of medical knowledge. A framework to relate the diagnosis process in Western Medicine and Traditional Chinese Medicine, as one of the various forms of CAM, is presented based on process-oriented analysis, hierarchical knowledge representation, relational database, and interactive interface for system utilization. The research is demonstrated using a case study on chronic prostatitis, and can be scalable to other medical conditions. The presented system for knowledge management is not intended to provide a definite solution for medical diagnosis, but to enable the exploration and discovery of knowledge for relational medical diagnosis. The results of this research will positively impact information distribution and knowledge generation via interactive medical knowledge systems, development of new skills for diagnosis and treatment, and a broader understanding of medical diseases and treatments.

Introduction: Forty years ago the life saving and life prolonging therapy of dialysis was rationed. It was extremely unlikely that people aged over 50 years would be offered treatment. Today, those aged over 65 years are becoming the fastest growing group of patients on dialysis. Changing population demographics and referral patterns, the opening up of eligibility for dialysis to high risk individuals, refinement and developments in dialysis technology and its ‘success’ in keeping more patients alive for longer periods, along with rising public expectation, are just some of the reasons behind this change in the age profile of those being currently treated for kidney failure. Older people are likely to have multiple co-morbidities and decreased functional status that may complicate their decision-making about dialysis and limit their treatment options. / Enhancing choice and involvement in treatment decision-making to the patient’s satisfaction is a central theme of health care ethics. Current national and international ethical guidelines about the initiation of dialysis recommend shared or joint decision-making and discuss patient ‘benefit’ and patient ‘need’. This project sought to determine how these recommendations, and other ethical issues related to informed consent, possible withdrawal of treatment and quality of life, were embodied in the personal experiences of a group of older people facing dialysis decisions. / Aim: The general aim of this research was to follow the dialysis decision-making process over time amongst a group of people aged 65 years and older. More specifically, this research sought to explore with the participants the following issues: what factors impacted on their dialysis decision-making; how they understood both what was happening to them and the goals of treatment; their preferences for information seeking; how they perceived any future decision-making; how or whether the commencement and experience of dialysis influenced their decision-making; and once treatment had been initiated, how they felt about their initial decisions. / Method: A predominantly longitudinal qualitative study was undertaken. Meetings were conducted prior to the potential initiation of dialysis with 21 participants. These meetings involved a semi-structured interview and the administration of three questionnaires focusing on preferences for decision-making, information seeking and quality of life. Data was also collected from the participants’ health records. For those participants who commenced dialysis a further two meetings were undertaken one month and then six months after treatment was instigated. The qualitative data was analysed thematically using concepts that had either been pre-determined and explored within the interviews or, had emerged from the participants’ stories. / Findings: Findings from this study include: participants not feeling that they had a choice about dialysis; a mismatch between theoretical expectations of informed consent and shared decision-making and the ‘actor centred experiential’ model of decision-making adopted by participants; a need to re-evaluate the balance and relationships between physiological measures of effectiveness emphasised by health professionals, and psychosocial and functional markers valued by participants; and treatment goals not being individually negotiated. / Conclusion: An interest in remaining alive was the driving force behind why participants chose to have dialysis. Other factors impacting on decisions about dialysis were multi-faceted and were based on priorities other than what health professionals consider important. Shared decision-making, as described in the literature, is not unproblematic. However, health professionals need to accept the underlying premises on which shared decision-making is based so that they can find out what expectations patients have of treatment, beyond that of saving life. Such expectations need to be discussed with patients and the various treatment options need to be negotiated in an attempt to achieve patients’ goals. Patients should be encouraged however to be involved in decision-making to the extent to which they desire.

No description available.

The prevalence of medical misdiagnosis has remained high despite the adoption of diagnostic software. This ongoing controversy about the role of technology in mitigating the problem of misdiagnosis centers on the question of whether diagnostic software does reduce the incidence of misdiagnosis if properly relied upon by physicians. The purpose of this quantitative, cross-sectional study based on planned behavior theory was to measure doctors' opinions of diagnostic technology's medical utility. Recruitment e-mails were sent to 3,100 AMA-accredited physicians through their database that yielded a sample of 99 physicians for the study. One-sample t tests and, where appropriate because of non-normal data, one-sample Wilcoxon signed-rank tests were conducted on the data to address the following key research questions on whether diagnostic software decreases misdiagnosis in healthcare versus unassisted human diagnostic method, if physicians use diagnostic software frequently enough to decrease misdiagnosis in healthcare, and if liability concerns prevent physicians from using diagnostic software. It was found that in the opinion of those surveyed (a) diagnostic software was likely to result in fewer misdiagnoses in healthcare than unassisted human diagnostic methods, (b) when speaking for themselves, physicians thought they used diagnostic software frequently enough to decrease misdiagnoses, and (c) physicians agreed they were not prevented from using diagnostic software because of liability concerns. The study's social significance is the affirmation of diagnostic software's usefulness: Policy and technology stakeholders can use this finding to speed the adoption of diagnostic software, leading to a reduction in the socially costly problem of misdiagnosis.