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Decomposing clinical practice guidelines panels' deliberation into decision theoretical constructs.

Benjamin Djulbegovic1,2,3, Iztok Hozo4, David Lizarraga1,2,3

  • 1Department of Computational & Quantitative Medicine, Beckman Research Institute, Duarte, California, USA.

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|January 25, 2023
PubMed
Summary
This summary is machine-generated.

Clinical practice guidelines for pulmonary embolism (PE) management lack a transparent framework. Decision models reveal discrepancies with American Society of Haematology (ASH) recommendations, highlighting the need for improved guideline development.

Keywords:
clinical decision makingdecision theoryevidence based medicinegroup decision makingpractice guidelines

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Area of Science:

  • Decision Analysis
  • Clinical Practice Guidelines
  • Medical Informatics

Background:

  • Clinical practice guideline (CPG) development often lacks explicit frameworks for synthesizing evidence into recommendations.
  • The American Society of Haematology (ASH) CPG for pulmonary embolism (PE) management was analyzed to assess its alignment with decision-theoretical constructs.
  • Understanding this alignment is crucial for improving the transparency and coherence of CPG development.

Purpose of the Study:

  • To evaluate the agreement between ASH CPG recommendations for PE management and explicit decision-modeling frameworks.
  • To identify potential discrepancies in decision-making processes used in CPG development.
  • To propose improvements for a more transparent and coherent CPG formulation process.

Main Methods:

  • Five decision-theoretical constructs were identified, with three applied: expected utility threshold (EUT), acceptable regret threshold (ARg), and fast-and-frugal trees (FFT).
  • Four PE management strategies were compared: withholding testing, ASH-Low (d-dimer then CTPA), ASH-High (CTPA then d-dimer), and treatment without testing.
  • Panel deliberations were matched with decision-modeling constructs to reformulate recommendations.

Main Results:

  • Different decision models generated significantly different recommendations compared to the ASH panel.
  • The EUT model suggested withholding testing below a 0.13% pre-test probability of PE, a threshold far below the ASH guideline's 2% post-test probability.
  • Agreement among models was limited, with consensus only on specific strategy applications within narrow pre-test probability ranges for PE.

Conclusions:

  • CPG panels utilize diverse decision-theoretical strategies, but their deliberations may lack necessary coherence.
  • ASH CPG recommendations for PE management often diverge from standard EUT decision analysis.
  • There is a need for more explicit and transparent frameworks in CPG development to ensure consistency and reliability.