Decision analysis in evidence-based decision making

Many real world decisions have to be made on a limited evidence base, and c linical decisions are at best problematic. We explored some of the reasons why decision making in health care is so complex, and examined how decision analytic techniques might contribute to problem structuring and to impleme ntation of evidence-based practice. We argued that decision analysis could, to some extent, overcome complexity of decision making by a clear structur ing of the problem and a formal analysis of the implications of different d ecisions. Decision-analytic techniques can guide the management of individu al patients or can be used to address policy questions about the use of tre atment for groups of patients, However: decision analysis is not without it s criticisms, e.g. problems are narrowly defined, replacing judgement and d ehumanizing care, neglect of process utility and lack of primary data to de velop decision analytic models. The development of evidence-based guideline s is a key component of the UK Government's quality strategy led by the Nat ional Institute for Clinical Excellence (NICE). However, the guidelines app roach may lead to conflict when assessments of the effectiveness of interve ntions for individuals (whether or not supported by a formal decision analy sis) conflict with the recommendations made by NICE for cost and clinical e ffectiveness for aggregate groups of patients. Decision analysis may or may not help with this but if guidelines are derived from a decision analysis, then the implications of patient preferences should be made clearer. Howev er, decision analysis-derived guidelines will make general recommendations that may not be appropriate for all individuals. Nonetheless, decision anal ysis does make such implications explicit and propose that the guidelines s hould be supported by some mechanism for determining individual patient pre ferences. It will now need to consider whether some of NICE resources shoul d be directed beyond evidence-based guidelines into decision analysis-deriv ed guidelines and into decision analytical techniques to provide support fo r clinical and cost effective decision making within the patient-clinician encounter.