A conditional model of evidence-based decision making.
OBJECTIVE
Efforts to describe how individual treatment decisions are informed by systematic knowledge have been hindered by a standard that gauges the quality of clinical decisions by their adherence to guidelines and evidence-based practices. This paper tests a new contextual standard that gauges the incorporation of knowledge into practice and develops a model of evidence-based decision making. Previous work found that the forecasted outcome of a treatment guideline exerts a highly significant influence on how it is used in making decisions. This study proposed that forecasted outcomes affect the recognition of a treatment scenario, and this recognition triggers distinct contextual decision strategies.


METHODS
Twenty-one volunteers from a psychiatric residency programme responded to 64 case vignettes, 16 in each of the four treatment scenarios. The vignettes represented a fully balanced within-subjects design that included guideline switching criteria and patient-specific factors. For each vignette, participants indicated whether they endorsed the guideline's recommendation.


RESULTS
Clinicians used consistent contextual decision strategies in responding to clearly positive or negative forecasts. When forecasts were more ambiguous or risky, their strategies became complex and relatively inconsistent.


CONCLUSIONS
The results support a three-step model of evidence-based decision making, in which clinicians recognize a decision scenario, apply a simple contextual strategy, then if necessary engage a more complex strategy to resolve discrepancies between general guidelines and specific cases. The paper concludes by noting study limitations and discussing implications of the model for future research in clinical and shared decision making, training and guideline development.
Falzer
Paul R
PR
VA Connecticut Healthcare System, West Haven, CT 06516, USA. paul.falzer@yale.edu
Garman
Melissa D
MD
D000328:Adult; D014150:Antipsychotic Agents / Q000627:therapeutic use; D003657:Decision Making; D004503:Education, Medical, Graduate; D019317:Evidence-Based Medicine; D005260:Female; D006801:Humans; D007396:Internship and Residency; D016014:Linear Models; D008297:Male; D017410:Practice Guidelines as Topic; D011570:Psychiatry / Q000193:education*
D014150:Antipsychotic Agents