Department of Clinical Sciences, Institute of Tropical Medicine, Antwerpen, Belgium
Department of Clinical Sciences, Institute of Tropical Medicine, Antwerpen, Belgium.
BMJ Evid Based Med. 2023 Nov 22;28(6):392-398. doi: 10.1136/bmjebm-2023-112350.
In clinical decision-making, physicians take actions such as prescribing treatment only when the probability of disease is sufficiently high. The lowest probability at which the action will be considered, is the action threshold. Such thresholds play an important role whenever decisions have to be taken under uncertainty. However, while several methods to estimate action thresholds exist, few methods give satisfactory results or have been adopted in clinical practice. We piloted the adapted nominal group technique (aNGT), a new prescriptive method based on a formal consensus technique adapted for use in clinical decision-making.
DESIGN, SETTING AND PARTICIPANTS: We applied this method in groups of postgraduate students using three scenarios: treat for rifampicin-resistant tuberculosis (RR-TB), switch to second-line HIV treatment and isolate for SARS-CoV-2 infection.
The participants first summarise all harms of wrongly taking action when none is required and wrongly not taking action when it would have been useful. Then they rate the statements on these harms, discuss their importance in the decision-making process, and finally weigh the statements against each other.
The resulting consensus threshold is estimated as the relative weights of the harms of the false positives divided by the total harm, and averaged out over participants. In some applications, the thresholds are compared with an existing method based on clinical vignettes.
The resulting action thresholds were just over 50% for RR-TB treatment, between 20% and 50% for switching HIV treatment and 43% for COVID-19 isolation. These results were considered acceptable to all participants. Between sessions variation was low for RR-TB and moderate for HIV. Threshold estimates were moderately lower with the method based on clinical vignettes.
The aNGT gives sensible results in our pilot and has the potential to estimate action thresholds, in an efficient manner, while involving all relevant stakeholders. Further research is needed to study the value of the method in clinical decision-making and its ability to generate acceptable thresholds that stakeholders can agree on.
在临床决策中，医生只有在疾病的概率足够高时才会采取治疗措施。医生将采取行动的最低概率称为行动阈值。在不确定的情况下，做出决策时，这种阈值就显得尤为重要。然而，虽然有几种估计行动阈值的方法，但很少有方法能给出令人满意的结果，或在临床实践中得到应用。我们尝试了一种新的规范性群组技术（aNGT），这是一种基于正式共识技术并适用于临床决策的新的规范性方法。
设计、地点和参与者：我们在研究生群体中使用三种情况来应用这种方法：治疗利福平耐药结核病（RR-TB）、转换二线抗 HIV 治疗以及隔离 SARS-CoV-2 感染。
参与者首先总结了在不需要采取行动时采取行动和在需要采取行动时不采取行动的所有错误行为的危害。然后，他们对这些危害的说法进行了评估，讨论了它们在决策过程中的重要性，最后相互权衡了这些说法。
产生的共识阈值是将错误阳性的危害的相对权重除以总危害，并在参与者中平均得出。在某些应用中，将这些阈值与基于临床病例的现有方法进行了比较。
RR-TB 治疗的行动阈值略高于 50%，HIV 转换治疗的阈值在 20%至 50%之间，COVID-19 隔离的阈值为 43%。所有参与者都认为这些结果是可以接受的。RR-TB 的组间变异较小，HIV 的组间变异中等。基于临床病例的方法得到的阈值估计值略低。
aNGT 在我们的初步研究中得出了合理的结果，有可能以有效的方式估计行动阈值，同时让所有相关利益相关者参与其中。需要进一步研究该方法在临床决策中的价值及其生成利益相关者可接受的阈值的能力。
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