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Multi-Criteria Clinical Decision Support

A Primer on the Use of Multiple-Criteria Decision-Making Methods to Promote Evidence-Based, Patient-Centered Healthcare

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Abstract

Current models of healthcare quality recommend that patient management decisions be evidence based and patient centered. Evidence-based decisions require a thorough understanding of current information regarding the natural history of disease and the anticipated outcomes of different management options. Patient-centered decisions incorporate patient preferences, values, and unique personal circumstances in the decision-making process, and actively involve both patients and healthcare providers as much as possible. Fundamentally, therefore, evidence-based, patient-centered decisions are multi-dimensional and typically involve multiple decision makers.

Advances in the decision sciences have led to the development of a number of multiple-criteria decision-making methods. These multi-criteria methods are designed to help people make better choices when faced with complex decisions involving several dimensions. They are especially helpful when there is a need to combine ‘hard data’ with subjective preferences, to make trade-offs between desired outcomes, and to involve multiple decision makers. Evidence-based, patient-centered clinical decision making has all of these characteristics. This close match suggests that clinical decision-support systems based on multi-criteria decision-making techniques have the potential to enable patients and providers to carry out the tasks required to implement evidence-based, patient-centered care effectively and efficiently in clinical settings.

The goal of this article is to give readers a general introduction to the range of multi-criteria methods available and show how they could be used to support clinical decision making. Methods discussed include the balance sheet, the ‘even swap’ method, ordinal ranking methods, direct weighting methods, multi-attribute decision analysis, and the analytic hierarchy process.

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Acknowledgements

This work was supported by grant 5K24HL093488-02 from the National Heart Lung and Blood Institute (NHLBI), US National Institutes of Health. The NHLBI played no other part in the preparation of this manuscript.

The author has no conflicts of interest that are relevant to the content of this article.

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Authors and Affiliations

  1. Department of Community and Preventive Medicine, University of Rochester, 601 Elmwood Ave, Box 644, Rochester, New York, 14642, USA

    James G. Dolan MD

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  1. James G. Dolan MD
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Correspondence to James G. Dolan MD.

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Appendix 1

Appendix 1

Glossary of Multi-Criteria Terms

Additive weighting method: A method of determining the overall scores of decision options analogous to calculating a weighted average. Calculated by multiplying the options’ scores on the criteria times the weights of the criteria and summing across all criteria.

Alternative: A course of action being actively considered as part of a decision-making process. Used interchangeably with option.

Attribute: A characteristic or feature of a decision option.

Common adverse effect: An adverse effect of a medication that causes temporary symptoms, such as rash or headache, that generally require minimal treatment for control and do not necessarily indicate that the causative medication needs to be discontinued.

Compensatory method: Decision-making methods that incorporate information from all the decision criteria.

Consistency: The extent to which a set of related judgments are internally consistent with each other.

Criterion: Consideration being used to select a preferred alternative in making a decision. Usually refers to attributes or characteristics of the alternatives that determine their desirability. Used interchangeably with objective.

Decision elements: The components of a decision, including the decision goal, the criteria and sub-criteria, and the alternatives being considered.

Decision model: A graphic representation of a decision that lists the options being considered and the considerations being used to compare the options. Sometimes a decision goal is also included. The format used is variable. Common arrangements include hierarchies and networks.

Decomposed approach: A method of decision analysis that breaks a decision down into separate elements such as alternatives and criteria.

Dimension: An important consideration in making a decision.

Dominated alternative: A decision alternative that has no unique advantages compared with the other alternatives being considered and is always inferior to at least one other alternative for every dimension.

Interval scale: A scale of measurement where there is a defined distance between any two points on the scale.

Non-compensatory method: Decision-making methods that do not incorporate information from all the decision criteria.

Objective: Consideration being used to select a preferred alternative in making a decision. Usually refers to attributes or characteristics of the alternatives that determine their desirability. Used interchangeably with criterion.

Option: A course of action being actively considered as part of a decision-making process. Used interchangeably with alternative.

Ordinal scale: A scale of measurement that involves assigning items to higher or lower ranks. No information is provided about the magnitude of the differences between the ranks.

Pairwise: A procedure involving a pair of items. Most commonly used to describe a process of making judgments between two decision elements.

Proximate criteria: Criteria and sub-criteria that are directly linked to decision options in a decision model.

Ratio level scale: A scale of measurement where there is both a defined distance between any two points on the scale and an absolute zero point. This is the only type of scale where ratios between numbers have meaning.

Score: A number representing the relative importance of a decision element in making a choice between a set of options. Most commonly applied to options.

Serious adverse effect: An adverse effect of a medication that requires substantial treatment for control, could result in permanent effects, and requires discontinuation of the causative drug.

Value tree: A hierarchical decision model with the goal of the decision on the highest level, the options on the lowest level, and the criteria and sub-criteria being used to compare the options relative to the goal in the middle.

Value-based methods: Multi-criteria methods that develop quantitative measures of how well the options fulfill the criteria and the relative impacts of the criteria in achieving the goal of the decision.

Weight: A number representing the relative importance of a decision element in making a choice between a set of options. Most commonly applied to criteria and sub-criteria.

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Dolan, J.G. Multi-Criteria Clinical Decision Support. Patient-Patient-Centered-Outcome-Res 3, 229–248 (2010). https://doi.org/10.2165/11539470-000000000-00000

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