Be warned — this book may change your life | |
Decision making in health and medicine. Integrating evidence and values. M G Myriam Hunink, Paul P Glasziou, Joanna E Siegel et al. Cambridge: Cambridge University Press, 2001 (xvi + 388 pp). ISBN 0 521 77029 7. |
Like the practice
of medicine itself, this book is not for the faint-hearted. Not because it is difficult to read or to understand, but because, unless you are already skilled in decision analysis, you will find it new, thought provoking and rigorous. The consequences of embracing its message are profound.
Its fundamental premiss is that medicine (defined in its broadest sense to cover clinical medicine, population research, policy development and health management) is about uncertainty and the need to make decisions despite this uncertainty. For example, you have just diagnosed a 58-year-old man with atrial fibrillation. If you prescribe warfarin you can reduce his risk of embolic stroke by 70%, but this benefit comes at the price of an increased risk of haemorrhage, and the need for regular blood tests and avoidance of activities that increase his risk of injury. How do you weigh up the probabilities and incorporate into the decision your patient’s individual values about what is important to him? This book presents an approach and a handful of tools for making complex, value-laden decisions such as this. The approach, PROACTIVE, is adapted from a generic approach to decision making. As the authors say, one of its greatest strengths is that it requires you to make the decision-making process transparent. By carefully outlining your decision, viewing it from other perspectives and considering what the important objectives are, the best decision may become readily apparent without having to go any further. If you need to work quantitatively with probabilistic data, to make trade-offs between benefits and risks (or length of life versus quality of life, or costs versus benefits), and to incorporate people’s values and preferences, the book provides detailed guidance on the tools that are available. It takes the novice from a definition of a probability and a proportion all the way to advanced microsimulation modelling. Decision making in health and medicine updates the 1980 book Clinical decision analysis. It has a broader framework, and covers population health decision-making. It also includes more information on diagnostic testing, methods for measuring and incorporating quality-of-life measures and newer approaches to modelling. To support it, there is an accompanying CD with solutions to exercises, decision-analytical software, examples of decision-analytic models using the software, spreadsheets and references with abstracts. It is an extraordinarily ambitious book that achieves its aim. Alexandra L Barratt
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