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Redelmeier DA, Shafir E. Post Hoc Bias in Treatment Decisions. JAMA Netw Open 2024; 7:e2431123. [PMID: 39230904 PMCID: PMC11375477 DOI: 10.1001/jamanetworkopen.2024.31123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/05/2024] Open
Abstract
Importance A goal of health care is to reduce symptoms and improve health status, whereas continuing dubious treatments can contribute to complacency, discourage the search for alternatives, and lead to shortfalls in care. Objective To test a potential bias in intuitive reasoning following a marginal improvement in symptoms after a dubious treatment (post hoc bias). Design, Setting, and Participants Surveys eliciting treatment recommendations for hypothetical patients were sent to community members throughout North America recruited via an online survey platform in the early winter months of 2023 and 2024 and presented to health care professionals (pharmacists who were approached in person using a secret shopper technique) in the summer months of 2023. Exposure Respondents received randomized versions of surveys that differed according to whether vague symptoms improved or remained unchanged after a dubious treatment. Main Outcomes and Measures The primary outcome was a recommendation to continue treatment. Results In total, 1497 community members (mean [SD] age, 38.1 [12.5] years; 663 female [55.3%]) and 100 health care professionals were contacted. The first scenario described a patient with a sore throat who took unprescribed antibiotics; respondents were more likely to continue antibiotics after initial treatment if there was a marginal improvement in symptoms vs when symptoms remained unchanged (67 of 150 respondents [45%] vs 25 of respondents [17%]; odds ratio [OR], 3.98 [95% CI, 2.33-6.78]; P < .001). Another scenario described a patient with wrist pain who wore a copper bracelet; respondents were more likely to continue wearing the copper bracelet after initial care was followed by a marginal improvement in symptoms vs when symptoms remained unchanged (78 of 100 respondents [78%] vs 25 of 99 respondents [25%]; OR, 16.19 [95% CI, 5.32-19.52]; P < .001). A third scenario described a patient with fatigue who took unprescribed vitamin B12; respondents were more likely to continue taking vitamin B12 when initial treatment was followed by a marginal improvement in symptoms vs when symptoms remained unchanged (80 of 100 respondents [80%] vs 33 of 100 respondents [33%]; OR, 7.91 [95% CI, 4.18-14.97]; P < .001). Four further scenarios involving dubious treatments found similar results, including when tested on health care professionals. Conclusions and Relevance In this study of clinical scenarios, a marginal improvement in symptoms led patients to continue a dubious and sometimes costly treatment, suggesting that clinicians should caution patients against post hoc bias.
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Affiliation(s)
- Donald A Redelmeier
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Evaluative Clinical Sciences Program, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Division of General Internal Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Center for Leading Injury Prevention Practice Education & Research, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Eldar Shafir
- Department of Psychology, Princeton University, Princeton, New Jersey
- Princeton School of Public and International Affairs, Princeton, New Jersey
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Boulet L, Consiglio M, Marini H, Lebaron C, Bellet V, Merle V. Patients' Experience and Satisfaction Regarding the Pre-Operative Shower: The PRODOUCH Multicenter Descriptive Survey. Surg Infect (Larchmt) 2024; 25:206-212. [PMID: 38466958 DOI: 10.1089/sur.2023.329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/13/2024] Open
Abstract
Background: Patients' experience of the pre-operative shower remains poorly assessed in the literature although it is an essential step in the prevention of surgical site infection. For obese patients, a pre-operative shower could be challenging. The goal was to assess patient satisfaction and experience with the process of pre-operative shower, and the effect of obesity status. Patients and Methods: This study was a multicenter prospective survey of consecutive surgical patients from nine hospitals. Data on the pre-operative shower were collected via telephone interview two to four weeks after surgery, and included the place (hospital, home), time, information received, difficulties experienced, the presence or absence of a visual assessment of skin cleanliness by a healthcare professional after the pre-operative shower, and overall patient satisfaction with the pre-operative shower technique. Data on the surgical procedure and patients' characteristics were collected from patients' records, and included age, gender, and body mass index. Factors associated with patient satisfaction were assessed. Results: Among 430 patients, 91.6% declared having received information on the pre-operative shower and 94.8% were very or rather satisfied with the pre-operative shower. Two factors were independently associated with satisfaction: showering at home and having received information on the pre-operative shower, but not obesity status. Only 17% of patients reported a visual assessment of skin cleanliness by a healthcare professional after the pre-operative shower. Discussion: Overall, regardless of obesity status, patients were satisfied with the pre-operative shower and reported no difficulties. However, this survey highlights the fact that skin cleanliness was seldom assessed by healthcare professionals, which may represent an unidentified weakness in skin preparation before surgery.
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Affiliation(s)
- Ludivine Boulet
- Department of Hospital Infection Control and Epidemiology, Rouen University Hospital, Rouen, France
- Dynamiques et Évènements des Soins et des Parcours, Rouen University Hospital, Rouen, France
| | - Mélanie Consiglio
- Department of Hospital Infection Control and Epidemiology, Rouen University Hospital, Rouen, France
- Dynamiques et Évènements des Soins et des Parcours, Rouen University Hospital, Rouen, France
| | - Hélène Marini
- Department of Hospital Infection Control and Epidemiology, Rouen University Hospital, Rouen, France
- Dynamiques et Évènements des Soins et des Parcours, Rouen University Hospital, Rouen, France
| | - Christine Lebaron
- Department of Hospital Infection Control and Epidemiology, Rouen University Hospital, Rouen, France
| | - Véronique Bellet
- Department of Hospital Infection Control and Epidemiology, Rouen University Hospital, Rouen, France
| | - Véronique Merle
- Department of Hospital Infection Control and Epidemiology, Rouen University Hospital, Rouen, France
- Dynamiques et Évènements des Soins et des Parcours, Rouen University Hospital, Rouen, France
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Redelmeier DA, Zipursky JS. A Dose of Reality About Dose-Response Relationships. J Gen Intern Med 2023; 38:3604-3609. [PMID: 37783979 PMCID: PMC10713937 DOI: 10.1007/s11606-023-08395-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 08/24/2023] [Indexed: 10/04/2023]
Abstract
Observational research can be strengthened by examining potential dose-response relationships that correlate a clinical intervention with a patient outcome. Despite being a classic criterion for establishing causality, dose-response testing can be difficult to interpret in clinical medicine due to multiple diverse pitfalls. This review introduces a cautionary framework for investigators considering dose-response relationships in observational research to support evidence-based medicine. Each pitfall is illustrated with a specific example relevant when analyzing a dose-response relationship. Several pitfalls stem from faulty interpretation including confounding by indication and fallible range selection. Additional pitfalls relate to improper analysis including fitting a nonlinear model and misclassification error. Further pitfalls arise in special situations including subjective self-report and artifacts from survival bias. These caveats are common sources of misunderstanding in analyses that examine the link between varying exposures and the intensity of clinical outcomes. Awareness of specific pitfalls, we suggest, might help advance the conduct, application, and translation of dose-response relationships in observational research to inform evidence-based medical care.
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Affiliation(s)
- Donald A Redelmeier
- Department of Medicine, University of Toronto, Toronto, Canada.
- Evaluative Clinical Sciences Program, Sunnybrook Research Institute, Toronto, Canada.
- Institute for Clinical Evaluative Sciences, Toronto, Canada.
- Division of General Internal Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada.
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
| | - Jonathan S Zipursky
- Department of Medicine, University of Toronto, Toronto, Canada
- Evaluative Clinical Sciences Program, Sunnybrook Research Institute, Toronto, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Canada
- Division of General Internal Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
- Division of Clinical Pharmacology & Toxicology, University of Toronto, Toronto, Canada
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Redelmeier DA, Etchells EE, Najeeb U. Psychology of envy towards medical colleagues. J R Soc Med 2023:1410768231182880. [PMID: 37378692 PMCID: PMC10387808 DOI: 10.1177/01410768231182880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2023] Open
Affiliation(s)
- Donald A Redelmeier
- Department of Medicine, University of Toronto, Toronto, ON, M5S 3H2, Canada
- Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada
- Institute for Clinical Evaluative Sciences in Ontario, Toronto, ON M4N 3M5, Canada
- Division of General Internal Medicine, Sunnybrook Health Science Centre, Toronto ON M4Y 3M5, Canada
- Centre for Quality Improvement and Patient Safety, University of Toronto, Toronto, ON, M5T 3M6, Canada
| | - Edward E Etchells
- Department of Medicine, University of Toronto, Toronto, ON, M5S 3H2, Canada
- Division of General Internal Medicine, Sunnybrook Health Science Centre, Toronto ON M4Y 3M5, Canada
- Centre for Quality Improvement and Patient Safety, University of Toronto, Toronto, ON, M5T 3M6, Canada
- Division of General Internal Medicine, Women's College Hospital, Toronto, ON M5S 1B2, Canada
| | - Umberin Najeeb
- Department of Medicine, University of Toronto, Toronto, ON, M5S 3H2, Canada
- Division of General Internal Medicine, Sunnybrook Health Science Centre, Toronto ON M4Y 3M5, Canada
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Redelmeier DA, Shafir E. The Fallacy of a Single Diagnosis. Med Decis Making 2023; 43:183-190. [PMID: 36059266 PMCID: PMC9827477 DOI: 10.1177/0272989x221121343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Accepted: 08/03/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND Diagnostic reasoning requires clinicians to think through complex uncertainties. We tested the possibility of a bias toward an available single diagnosis in uncertain cases. DESIGN We developed 5 different surveys providing a succinct description of a hypothetical individual patient scenaric. Each scenario was formulated in 2 versions randomized to participants, with the versions differing only in whether an alternative diagnosis was present or absent. The 5 scenarios were designed as separate tests of robustness using diverse cases, including a cautious scenario, a risky scenario, a sophisticated scenario, a validation scenario, and a comparative scenario (each survey containing only 1 version of 1 scenario). Participants included community members (n = 1104) and health care professionals (n = 200) who judged the chances of COVID infection in an individual patient. RESULTS The first scenario described a cautious patient and found a 47% reduction in the estimated odds of COVID when a flu diagnosis was present compared with absent (odds ratio = 0.53, 95% confidence interval 0.30 to 0.94, P = 0.003). The second scenario described a less cautious patient and found a 70% reduction in the estimated odds of COVID in the presence of a flu diagnosis (odds ratio = 0.30, 95% confidence interval 0.13 to 0.70, P < 0.001). The third was a more sophisticated scenario presented to medical professionals and found a 73% reduction in the estimated odds of COVID in the presence of a mononucleosis diagnosis (odds ratio = 0.27, 95% confidence interval 0.10 to 0.75, P < 0.001). Two further scenarios-avoiding mention of population norms-replicated the results. LIMITATIONS Brief hypothetical scenarios may overestimate the extent of bias in more complicated medical situations. CONCLUSIONS These results demonstrate that an available simple diagnosis can lead individuals toward premature closure and a failure to fully consider additional severe diseases. HIGHLIGHTS Occum's razor has been debated for centuries yet rarely subjected to experimental testing for evidence-based medicine.This article offers direct evidence that people favor an available simple diagnosis, thereby neglecting to consider additional serious diseases.The bias can lead individuals to mistakenly lower their judged likelihood of COVID or another disease when an alternate diagnosis is present.This misconception over the laws of probability appears in judgments by community members and by health care workers.The pitfall in reasoning extends to high-risk cases and is not easily attributed to information, incentives, or random chance.
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Affiliation(s)
- Donald A. Redelmeier
- Department of Medicine, University of Toronto,
Toronto, ON, Canada
- Evaluative Clinical Sciences Program,
Sunnybrook Research Institute, Toronto, ON, Canada
- Institute for Clinical Evaluative Sciences,
Toronto, ON, Canada
- Division of General Internal Medicine,
Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Center for Leading Injury Prevention Practice
Education & Research, Toronto, ON, Canada
| | - Eldar Shafir
- Department of Psychology, Princeton University,
Princeton, NJ, USA
- Princeton School of Public and International
Affairs, Princeton University, Princeton, NJ, USA
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Redelmeier DA, Etchells EE, Najeeb U. Honest communication and social asymmetries inside a hospital: Pitfalls for clinicians. J Hosp Med 2022; 17:405-409. [PMID: 35535568 DOI: 10.1002/jhm.12827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 04/05/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Donald A Redelmeier
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Evaluative Clinical Sciences Platform, Sunnybrook Research Institute, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences in Ontario, Population Health Division, Toronto, Ontario, Canada
- Division of General Internal Medicine, Sunnybrook Health Science Centre, Toronto, Ontario, Canada
- Centre for Quality Improvement and Patient Safety, University of Toronto, Toronto, Ontario, Canada
| | - Edward E Etchells
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of General Internal Medicine, Sunnybrook Health Science Centre, Toronto, Ontario, Canada
- Centre for Quality Improvement and Patient Safety, University of Toronto, Toronto, Ontario, Canada
- Division of General Internal Medicine, Women's College Hospital, Toronto, Ontario, Canada
| | - Umberin Najeeb
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of General Internal Medicine, Sunnybrook Health Science Centre, Toronto, Ontario, Canada
- Office of Inclusion and Diversity, Temerty Faculty of Medicine, Toronto, Ontario, Canada
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Redelmeier DA, Etchells EE, Najeeb U. Principles and Practice of Gossiping About Colleagues in Medicine. J Hosp Med 2021; 16:763-766. [PMID: 34798004 DOI: 10.12788/jhm.3702] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 08/24/2021] [Indexed: 11/20/2022]
Affiliation(s)
- Donald A Redelmeier
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Division of General Internal Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Centre for Quality Improvement and Patient Safety, University of Toronto, Toronto, Ontario, Canada
| | - Edward E Etchells
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of General Internal Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Centre for Quality Improvement and Patient Safety, University of Toronto, Toronto, Ontario, Canada
| | - Umberin Najeeb
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of General Internal Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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