Décision médicale, incertitude et complexité : de la construction de modèles d'aide à la décision à la diffusion de "bonnes" pratiques médicales
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Abstract EN:
Controlling health expenditures from a medical point of view implies the definition of "good" medical practices (gmp). Beyond their definitions, very few tools, allowing a systematic selection of these gmp, are put at the disposal of healthcare professionals. The analysis of the medical decision (md) is intended to enable the construction of models to assist decision making and the response to expectations of professionals of the sanitary sector. The md brings an action at the micro-social level of the physician-patient relationship. Our thesis therefore takes this relationship as a starting point, by using the theoretical limit of the "service relationship". The uncertainty and the complexity of the medical activity are the principal characteristics of this activity of service. We concentrate our attention on the central problem of reducing this uncertainty, often radical in this case, as regards the result of the service. The complexity of the activity derives from "the infinite diversity of case" that the physician meets. The emergence of gmp implies, considering the characteristics of the activity, the search for and the processing of a great deal of information, for which the therapist cannot be competent in the daily exercise of his activity. The construction of aid models for the md has to allow the production of information in far less quantity, entailing a substantial reduction in the inherent complexity of the medical activity. Multicriteria analyses of aid for the decision, based on the theoretical concepts of h. Simon's decision, have the ability to aggregate preferences without presumably reducing the field of the observable and seem well adapted to the aid for the md. This information, produced by these models of multicriterial inspiration, permits the creation of guides of gmp and may lead to the coordination of practitioners' behaviour, phenomenon comparable to the emergence of an economic "convention".
Abstract FR:
La maitrise medicalisee des depenses de sante implique la definition de + bonnes ; pratiques medicales (bpm). Audela de leurs definitions, tres peu d'outils permettant un choix systematise de ces bpm, sont mis a la disposition des professionnels de la sante. L'analyse de la decision medicale (dm) dans le but de construire des modeles d'aide a la decision peut permettre de repondre aux attentes des professionnels du secteur sanitaire. La dm s'exerce au niveau micro-social de la relation medecin-patient. Notre these prend donc comme point de depart cette relation, en s'appuyant sur le cadre theorique de la + relation de service ;. L'incertitude et la complexite de l'activite medicale sont les principales caracteristiques de cette activite de service. Nous focaliserons notre attention sur le probleme central de la reduction de l'incertitude, ici souvent radicale (non probabilisable), sur le resultat du service. La complexite de l'activite resulte de + l'infinie diversite des cas ; qui se presente au medecin. Par complexite, nous adopterons l'acception de la theorie des systemes, c'est-a-dire un systeme necessitant une quantite d'information inversement correlee a la variete du systeme. L'emergence de bpm suppose la recherche et le traitement d'une grande quantite d'informations, qui ne peut etre du ressort du praticien dans l'exercice quotidien de son activite. La construction de modeles d'aide a la dm vise a produire de l'information pertinente en quantite beaucoup moins importante, d'ou une forte reduction de la complexite inherente a l'activite medicale. Les analyses multicriteres d'aide a la decision, developpees sur la base des concepts theoriques de la decision de h. Simon, semblent bien adaptees a l'aide a la dm. Cette information produite par ces modeles d'inspiration multicritere permettent la creation de guides de bpm condition prealable a la coordination des comportements des prestataires, phenomene assimilable a l'emergence d'une + convention ; economique.