Les nouvelles technologies de l'information et de la communication constituent des outils utiles pour améliorer le système de santé. Les décisions relatives à leur mise en œuvre ainsi qu'à leur utilisation doivent être basées sur des observations solides pour évaluer les impacts sur les soins et la santé. L'utilisation difficile des méthodes d'évaluation économique est due à la multidimensionnalité de l'évaluation des implémentations de télémédecine. En effet, pour évaluer l'impact de l'introduction de la télémédecine, il est nécessaire de prendre en compte les indicateurs divers identifiées dans la littérature. En outre, ils doivent être considérés par rapport à tous les acteurs impliqués dans le processus de décision. Dans ce contexte, l'aide multicritère à la décision peut fournir des informations supplémentaires sur l'évaluation de la télémédecine. L'objectif de cette thèse est de présenter une méthodologie d'évaluation multicritère impliquant de multiples décideurs pour la mise en place d'unité de dialyse médicalisée avec télémédecine (UDMT). Pour prendre une décision, le directeur de l'hôpital souhaite prendre en compte, à côté des indicateurs mentionnés ci-dessus, les préférences des médecins et des patients. Pour expliciter ces préférences, nous suggérons de considérer que les patients et les médecins sont des décideurs qui exprime un classement des différentes modalités de soins qui sont évaluées sur plusieurs critères. Nous sommes face à une situation impliquant plusieurs juges qui recouvrent une multiplicité de points de vue. Pour résoudre ce problème, nous utilisons des techniques à la fois de la théorie du choix social et de l'aide multicritère à la décision. D'abord, nous proposons d'agréger les classements individuels des patients sur les différentes modalités de soins, ce classement est ensuite utilisé dans la phase d'élicitation des préférences des médecins. Les classements individuels de ces derniers sont ensuite agrégées dans un classement des médecins qui est ensuite combiné avec celui de patients et d'autres critères économiques pour déterminer les préférences du directeur d'hôpital sur les modalités de soins. Cette méthodologie est appliquée à la mise en œuvre d'unités de dialyse médicalisées en Bretagne, sur la base des préférences de patients, médecins et directeur de l'hôpital. Les préférences de tous les acteurs de ce processus de décision sont représentables par des modèles d'utilité additives. L'alternative préférée parmi les patients et les médecins est l'UDMT. Le critère qui a le plus d'impact sur la décision des patients (resp. Les médecins) est la distance de l'unité de dialyse (resp. La satisfaction des patients). Enfin, l'analyse montre que les critères les plus importants pour le directeur de l'hôpital sont la satisfaction des médecins et des patients. Ce travail montre qu'il est important de tenir compte de l'hétérogénéité et de la multiplicité des points de vue et des acteurs dans l'évaluation. / The new information and communication technologies represent useful tools for improving the health system. Decisions on their implementation and use must be based on solid observations to assess their impacts on care and health. The difficult use of classical economic evaluation methods is due to the multidimensionality of the assessment of telemedicine implementations. Indeed, to evaluate the impact of the introduction of telemedicine, it is necessary to take into account various indicators identified in the literature, as cost, accessibility, acceptability and quality. Furthermore, they need to be considered with respect to all the stakeholders involved in the decision process. In this context, decision support theories provide additional insight into the evaluation of telemedicine. The objective of this thesis is to present a multicriteria evaluation methodology involving multiple decision makers for the establishment of remotely monitored medical dialysis (RMMD) solutions. To reach a decision, the hospital director wishes to take into account, next to the above mentionned indicators, the preferences of the physicians and the dialysis patients. In order to explicit these preferences, we suggest to consider that the patients and the physicians are decision makers which have to express a ranking of care modalities evaluated on multiple criteria. We thus face a situation involving multiple judges which overlay a multiplicity of viewpoints. To solve this problem, we use techniques both from social choice theory and multicriteria decision analysis. First we propose to agregate the individual rankings of the patients on the potential multicriteria care modalities into a patient-wide order, which is then used in the multicriteria preference elicitation phasis of the physicians. The individual rankings of the latter ones is then aggregated into a physician-wide ranking which is then combined with the patients' one and further economical criteria to elicit the hospital director's preferences on the care modalities. This methodology is applied to the implementation of medical dialysis units in Brittany (France), on basis of the preferences of 16 patients, 8 physicians and 1 hospital director. The preferences of all the stakeholders of this decision process are representable by additive value models. The preferred alternative among the patients and the physicians is the medical dialysis unit with remote monitoring. The criterion which has the highest impact on the patients' (resp. physicians') decision is the distance to the dialysis unit (resp. the patients' satisfaction). Finally, the analysis shows that the most important criteria for the hospital director are the physicians' and the patients' satisfaction. This work shows that it is important to consider the heterogeneity and the multiplicity of viewpoints and actors in the evaluation of the implementation of RMMD solutions via multicriteria decision support techniques.

BACKGROUND: Medical professional organizations in the U.S. recommend shared decision-making for routine labor induction in healthy term pregnancies. Shared decision-making is part of high quality, person-centered care and has substantial positive impacts. Despite these recommendations for, and impacts of, shared decision-making many people, especially people of color and those who are Medicaid-insured, do not experience shared decision-making concerning induction and according to a 2020 scoping review there are no patient decision aids on this topic. METHODS: We used quality improvement and qualitative methods to develop, test, and refine a patient decision aid on labor induction in healthy pregnancies at or beyond 39 weeks to support shared decision-making. We assessed shared decision-making primarily with these outcomes: patients’ understanding of choices, pros and cons of choices, and their role as primary decision-maker. A quality improvement team developed an initial prototype and used Plan-Do-Study-Act cycles to get patient and provider feedback. The decision aid was tested in three languages by providers across obstetrics, family medicine, and midwifery at a tertiary hospital and two community health centers in Boston, MA between September 2020 and December 2021. RESULTS: Shared decision-making on labor induction in healthy pregnancies was achieved. Across three Plan-Do-Study-Act cycles 24 pregnant people were interviewed. Most were people of color and Medicaid-insured. Many were recent immigrants and/or non-Native English speakers. Nearly all interviewees experienced shared decision making: 23/24 understood their role as the decision-maker. The majority could name two or three choices they had and pros and cons of different choices. Many described the process as empowering and positive. Nine medical providers tested the decision aid and gave feedback. Providers said using the tool helped improve the consistency and content of their counseling and reduce the role of bias. CONCLUSION: A balanced, evidence-based decision aid can support patients and providers in achieving shared decision-making on induction. Quality improvement and qualitative methods were shown effective for decision aid development and can be applied to other topics within and beyond maternity care. Decision aids may be a meaningful part of efforts to improve equity when development, testing, and evaluation centers people with marginalized identities.

In the recent decades, therehave been frequent conflicts between groundwater waterresources and environmentally hazardous activities. Newmethodologies for aiding decision-making in groundwater impactassessment and protection areneeded and in which issues ofincreased awareness, better understanding of the groundwaterresources processes, and validation of predictive mathematicalmodels are addressed. A framework fordecision–aid, based on predictive simulations that a)predicts the environmental impacts b) provides the totaleconomical value c) visualises the impacts and the groundwaterproperties and d) describes the uncertainties in the results isproposed herein. The framework can be applied in environmentalimpact assessments, strategic environmental assessments andprotection and management of water resources. The results ofthe model are used as feedback for determining new scenarios,depending on the required uncertainties, and if the plannedactivity is sustainable, and/or fulfils the legislative andpolicy measures. This framework is applied to a particular casestudy, Nybroåsen, in the south-eastern part of Sweden,where the highway E22 is constructed through the importantglaciofluvial esker aquifer, passing the protection zone of thewater supply for the Kalmar municipality. The impacts from the new highwayand the existing road have been predicted by two-dimensionalphysically based time-variant flow and solute groundwatermodelling. The results, breakthrough curves of contaminantconcentration in wells and maps of concentration distributions,as well as travel times, flow paths, and capture zones forwells determined by particle tracking have been presented. The constructed model of theNybroåsen study area was calibrated by comparing observedand simulated groundwater levels for 15 observation wells forten years of measurements. The model has been evaluated bothgraphically and numerically and the calibration target wasfulfilled for 13 of the 15 observation wells. The model workincludes investigations of the catchment information, a waterbalance study, simulation of the groundwater recharge,consideration of the unsaturated zone by a numerical columnsimulation, and sensitivity analysis. From the sensitivity analysis ofthe flow and transport parameters, it has been shown that theuncertainties are mainly due to the hydraulic conductivity.Comparison of the derived conductivity from the steady-stateautomatic calibration and the time-variant calibration showedthat there are major differences in the derived parameters,which illustrates the importance of a time dependentcalibration over both wet and dry periods and in more than onepoint in the area of interest of the model predictions. In addition, a multi-criteriadecision analysis has been carried out for four roadalternatives (including the new highway E22) and the existingroad in the case study concerned. The multi-criteria decisionaid is applied as an illustration of how it can be used in thestudy area to identify a) interest groups of actors and theirconcerns b) ranking of alternative road scenarios according toactors’preferences and c) coalition groups of actorsi.e.groups that have similar views with regard to theroad alternatives. <b>Keywords:</b>Physically-based groundwater modelling,contamination, flow and solute transport, glaciofluvialdeposits, Nybroåsen, Sweden, and multi-criteriadecision-aid. / NR 20140805

Decision making processes of natural resources for sustainable development are very complex processes that contain large amounts of contradicting criteria and alternatives and/or objectives. Hence efficiency of planning and decision making is highly dependent on the structure of the decision problems. In this re-spect Multi Criteria Decision Aid (MCDA) is the most widely used method. Particularly GIS-based MCDA using the Analytical Hierarchy Process (AHP) is a well-known method in this respect. However, there are interrelationships and interdependences among problems of the real world. As a result, many spatial problems cannot be structured hierarchally because the importance of the criteria determines the importance of the alternatives, and the importance of the alternatives also determines the importance of the criteria. Analytical Network Process (ANP) based MCDA is a new planning and decision making ap-proach that allows the decision problem to be modeled considering feedbacks and interdependence among criteria. This study critically reviews GIS-based MCDA using the AHP method and the ANP based MCDA method and forwarded recommendations for future works. To attain this, practical decision making processes were used of urban form selection for a sustainable development of the Stockholm region. For this purpose literature was reviewed, separate methodologies were developed, criteria were formulated to be analyzed using GIS and SuperDecision software‟s, and finally reasonable results were achieved and separately presented to critically evaluate both the methods and the outcome. This study showed that GIS has the potential to be an important decision aid tool, that the ANP seems to give more realistic results than the GIS-based MCDA method, and that a compact scenario that over time follows already established polycentric pattern would be the best alternative urban form for a sustainable develop-ment of Greater Stockholm.

Indiana University-Purdue University Indianapolis (IUPUI) / Purpose The experience of surgical patient decision-making for amputation, rotationplasty, or limb salvage surgery for the lower extremity was explored with osteosarcoma survivors and parents. Issues and patient concerns were examined prospectively in Facebook posts and retrospectively in personal interviews. Recommendations were sought for the development of a decision aid. Methods A qualitative inquiry was conducted in two studies: 1) a content analysis of 15 Facebook posts on the Osteosarcoma and Ewing’s Sarcoma Support Group about the surgical decision, and 2) a narrative analysis of 20 interviews with survivors and parents about their lived experience. The interview guide was informed by a knowledge translation theoretical model. In-person or video interviews included 29 parents or adolescent-young adults between the ages of 14-71 across 15 states. Results Participants were concerned about making the best decision for themselves or their child. Having little time to make the decision contributes to feeling overwhelmed and uninformed. The lack of information about options, potential limitations, prosthetic needs, and long-term functional outcomes impacts the decision-making process. Resources for finding information are limited. Shared decision-making approaches were preferred though many decisions were made by the surgeon. Patients felt unprepared for complications encountered after limb salvage. Conclusions Limb salvage surgery remains the gold standard for most providers; participants felt there was a bias on the surgeon’s part for salvage. Potential complications and uncertainties of each option were largely omitted in consultations; information about living with a prosthesis is an unmet need for decision-making. The decision affected their quality of life in ways they did not anticipate, resulting in additional decisions. Implications The findings of this study can be used in medical education for orthopedic surgeons to understand the long-term outcomes of limb salvage surgery. Patient preferences matter in the decision and patients who are involved in the decision are more satisfied if they are prepared for the unknown and potential complications. Recommendations for a decision aid include an online format, content that includes a discussion of uncertainties as well as complications of each option, patient stories for long-term outcomes, and resources for psychosocial support.

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Computer Assisted Patient Decision Aids (CAPtDA) are important tools to address informed decision making. This parallel mixed methods study described patterns of use of a CAPtDA among men with early stage prostate cancer and explored their perceptions of a CAPtDA and its role in their decision-making process. Men (N=56) with early stage prostate cancer, seeking consultations for surgery and/or radiation therapy at Fox Chase Cancer Center, were recruited by telephone. Those who consented completed a background questionnaire prior to their initial treatment consult. Variables included demographics, decisional factors (such as decision-making style, treatment preference, stage of decision making, Ottawa decisional conflict) and health communication factors (health literacy and computer facility). The CAPtDA had embedded web log tracking capabilities. Men were also asked to participate in an in-depth qualitative interview within 2-4 weeks of their consult visit to explore their perceptions of the software. Twenty five men participated (14 surgical consult patients and 11 radiation consult patients). Specific CAPtDA components were more highly utilized while other components were rarely used. The Men's Stories, with actual men's stories about their diagnosis, treatment decision and challenges, was viewed by 77% of the men and they spent almost half of their time (46%) here. In contrast, the Notebook, which is the values clarification tool, was viewed by only 4 men and they spent about one minute in this section. Men with lower levels of health literacy spent more time in the Men's Stories than men with higher levels of literacy. However, literacy level was not associated with multiple uses and men reported that the content was easy to understand regardless of health literacy level. Those with higher decisional conflict spent more time overall and those who were less confident in their treatment choice were less likely to use it again. Fifteen percent of the sample was minority, but the drop-off rate in participation in the in-depth interviews among minorities and those with limited literacy was dramatic. Opening this "black box" showed different patterns of use and confirmed that not everyone uses it in the same way, or as we intend. / Public Health