Hierarchical decision models are a general decision support methodology aimed at the classification or evaluation of options that occur in decision-making processes. They are also important for the analysis, simulation and explanation of options. Decision models are typically developed through the decomposition of complex decision problems into smaller and less complex subproblems; the result of such decomposition is a hierarchical structure that consists of attributes and utility functions. This article presents an approach to the development and application of qualitative hierarchical decision models that is based on DEX, an expert system shell for multi-attribute decision support. The distinguishing characteristics of DEX are the use of qualitative (symbolic) attributes, and 'if-then' decision rules. Also, DEX provides a number of methods for the analysis of models and options, such as selective explanation and what-if analysis. We demonstrate the applicability and flexibility of the approach presenting four real-life applications of DEX in health care: assessment of breast cancer risk, assessment of basic living activities in community nursing, risk assessment in diabetic foot care, and technical analysis of radiogram errors. In particular, we highlight and justify the importance of knowledge presentation and option analysis methods for practical decision-making. We further show that, using a recently developed data mining method called HINT, such hierarchical decision models can be discovered from retrospective patient data.