Clinical decision consultation service.

Since 1978, decision analysis consultations have been offered to help physicians manage particularly vexing clinical problems. Consultations were requested for decisions perceived as difficult because: the diagnosis was uncertain; the available therapy had uncertain efficacy or risks; the patient had a short life expectancy that limited the potential benefit of therapy; the risk of a given test or therapy was increased and the usual rules for applying the test or giving the treatment did not apply; the need for a therapeutic procedure was acknowledged, but competing risks created uncertainty about the optimal timing of the procedure; the optimal sequence of multiple necessary procedures could not be discerned readily; explicit patient input into decision-making was required; certain medical information could not be interpreted easily; and a rare, unique, or new problem was encountered. To carry out these consultations, standard techniques were used, including decision tree models, Bayes' theorem, Markov analysis, and utility assessment, but old approaches were modified to adapt decision analysis to individual patient problems. This experience demonstrates that decision analysis can be carried out effectively on a consultative basis for individual patients. A consultation service can also train analysts in decision-making and drive research in medical problem solving.