Low-value care is increasingly recognized as a global problem that places strain on healthcare systems and has no quick fix. Verkerk et al. have identified key factors promoting low-value care on a... Show moreLow-value care is increasingly recognized as a global problem that places strain on healthcare systems and has no quick fix. Verkerk et al. have identified key factors promoting low-value care on a national level, proposed strategies to address these and create a healthcare system facilitating delivery of high-value care. In this commentary, we reflect on the results of Verkerk et al. and argue that uncertainty has a crucial role when it comes to reducing low value care. This uncertainty is reflected in lack of a shared view between stakeholders, with clear criteria and thresholds on what constitutes low-value care, and a cross-cutting theme related to the key factors identified. We suggest to work on such a shared view of low-value care and different from implementation efforts to explicitly address uncertainty and its driving cognitive biases grounded in human decision making psychology, to reduce low-value care. Show less
Multigene panel testing is mainly used to improve identification of genetic causes in families with characteristics fitting multiple possible cancer syndromes. This technique may yield uncertainty,... Show moreMultigene panel testing is mainly used to improve identification of genetic causes in families with characteristics fitting multiple possible cancer syndromes. This technique may yield uncertainty, for example when variants of unknown significance are identified. This study explores counsellors' and counselees' experiences with uncertainty, and how they discuss uncertainties and decide about multigene panel testing. Six focus groups were conducted including 38 counsellors. Twelve counselees who had received genetic counselling about a multigene panel test were interviewed. The focus group sessions and interviews were audio-recorded and transcribed verbatim. Transcripts were analysed inductively by two independent coders and data were examined to obtain a comprehensive list of themes. Counsellors identified several uncertainties, e.g. finding a variant of unknown significance, or detecting an unsolicited finding. Most difficulty was experienced in deciding what uncertain information to communicate to counselees and how to do so. The extent and manner of providing uncertain information differed between centres and between counsellors. Counsellors attached more value to counselees' preferences in decision making compared to less extended tests. Counselees experienced difficulty in recalling which uncertainties had been discussed during genetic counselling. They primarily reported to have experienced uncertainty about their own and their relatives' risk of developing cancer. Counselees felt they had had a say in the decision. This study showed that counsellors need more guidance on whether and how to convey uncertainty. Undesirable practice variation in the communication of uncertainty may be prevented by determining what information should minimally be discussed to enable informed decision making. Show less
Background Psychopathy has repeatedly been linked to disturbed associative learning from aversive events (i.e., threat conditioning). Optimal threat conditioning requires the generation of internal... Show moreBackground Psychopathy has repeatedly been linked to disturbed associative learning from aversive events (i.e., threat conditioning). Optimal threat conditioning requires the generation of internal representations of stimulus–outcome contingencies and the rate with which these may change. Because mental representations are imperfect, there will always be uncertainty about the accuracy of representations in the brain (i.e., representational uncertainty). However, it remains unclear 1) to what extent threat conditioning is susceptible to different types of uncertainty in representations about contingencies during the acquisition phase and 2) how representational uncertainty relates to psychopathic features. Methods A computational model was applied to functional neuroimaging data to estimate uncertainty in representations of contingencies (CoUn) and the rate of change of contingencies (RUn), respectively, from brain activation during the acquisition phase of threat conditioning in 132 adolescents at risk of developing antisocial personality profiles. Next, the associations between these two types of representational uncertainty and psychopathy-related dimensions were examined. Results The left and right amygdala activations were associated with CoUn, while the bilateral insula and the right amygdala were associated with RUn. Different patterns of relationships were found between psychopathic features and each type of uncertainty. Callous-unemotional traits and impulsive-irresponsible traits uniquely predicted increased CoUn, while only impulsive-irresponsible traits predicted increased RUn. Conclusions The findings suggest that 1) the insula and amygdala differ in how these regions are affected by different types of representational uncertainty during threat conditioning and 2) CoUn and RUn have different patterns of relationships with psychopathy-related dimensions. Show less
Steen, S.L. van der; Riedijk, S.R.; Verhagen-Visser, J.; Govaerts, L.C.P.; Srebniak, M.I.; Opstal, D. van; ... ; Galjaard, R.J.H. 2016
