Assessment of the sunk-cost effect in clinical decision-making

Identifying, Understanding, and Minimizing Unconscious Cognitive Biases in Perioperative Crisis Management: A Narrative Review

Rapid clinical decision-making behavior is often based on pattern recognition and other mental shortcuts. Although such behavior is often faster than deliberative thinking, it can also lead to errors due to unconscious cognitive biases (UCBs). UCBs may contribute to inaccurate diagnoses, hamper interpersonal communication, trigger inappropriate clinical interventions, or result in management delays. The authors review the literature on UCBs and discuss their potential impact on perioperative crisis management. Using the Scale for the Assessment of Narrative Review Articles (SANRA), publications with the most relevance to UCBs in perioperative crisis management were selected for inclusion. Of the 19 UCBs that have been most investigated in the medical literature, the authors identified 9 that were judged to be clinically relevant or most frequently occurring during perioperative crisis management. Formal didactic training on concepts of deliberative thinking has had limited success in reducing the presence of UCBs during clinical decision-making. The evolution of clinical decision support tools (CDSTs) has demonstrated efficacy in improving deliberative clinical decision-making, possibly by reducing the intrusion of maladaptive UCBs and forcing reflective thinking. Anesthesiology remains a leader in perioperative crisis simulation and CDST implementation, but spearheading innovations to reduce the adverse impact of UCBs will further improve diagnostic precision and patient safety during perioperative crisis management.

Limitation of Non-Beneficial Interventions and their Impact on the Intensive Care Unit Costs

Introduction

Using a plan to limit non-beneficial life support interventions has significantly reduced harm and loss of dignity for patients at the end of life. The association of these limitations with patients' clinical characteristics and health care costs in the intensive care unit (ICU) needs further scientific evidence.

Aim of the study

To explore decisions to limit non-beneficial life support interventions, their correlation with patients' clinical data, and their effect on the cost of care in the ICU.

Material and Methods

We included all patients admitted to the general ICU of a hospital in Greece in a two-year (2019-2021) prospective study. Data collection included patient demographic and clinical variables, data related to decisions to limit (withholding, withdrawing) non-beneficial interventions (NBIs), and economic data. Comparisons were made between patients with and without limitation decisions.

Results

NBIs were limited in 164 of 454 patients (36.12%). Patients with limitation decisions were associated with older age (70y vs. 62y; p<0,001), greater disease severity score (APACHE IV, 71 vs. 50; p<0,001), longer length of stay (7d vs. 4.5d; p<0,001), and worse prognosis of death (APACHE IV PDR, 48.9 vs. 17.35; p<0,001). All cost categories and total cost per patient were also higher than the patient without limitation of NBIs (9247,79€ vs. 8029,46€, p<0,004). The mean daily cost has not differed between the groups (831,24€ vs. 832,59€; p<0,716). However, in the group of patients with limitations, all cost categories, including the average daily cost (767.31€ vs. 649.12€) after the limitation of NBIs, were reduced to a statistically significant degree (p<0.001).

Conclusions

Limiting NBIs in the ICU reduces healthcare costs and may lead to better management of ICU resource use.

Comparison of clinical note quality between an automated digital intake tool and the standard note in the emergency department

BACKGROUND

Medical encounters require an efficient and focused history of present illness (HPI) to create differential diagnoses and guide diagnostic testing and treatment. Our aim was to compare the HPI of notes created by an automated digital intake tool versus standard medical notes created by clinicians.

METHODS

Prospective trial in a quaternary academic Emergency Department (ED). Notes were compared using the 5-point Physician Documentation Quality Instrument (PDQI-9) scale and the Centers for Medicare & Medicaid Services (CMS) level of complexity index. Reviewers were board certified emergency medicine physicians blinded to note origin. Reviewers received training and calibration prior to note assessments. A difference of 1 point was considered clinically significant. Analysis included McNemar's (binary), Wilcoxon-rank (Likert), and agreement with Cohen's Kappa.

RESULTS

A total of 148 ED medical encounters were charted by both digital note and standard clinical note. The ability to capture patient information was assessed through comparison of note content across paired charts (digital-standard note on the same patient), as well as scores given by the reviewers. Reviewer agreement was kappa 0.56 (CI 0.49-0.64), indicating moderate level of agreement between reviewers scoring the same patient chart. Considering all 18 questions across PDQI-9 and CMS scales, the average agreement between standard clinical note and digital note was 54.3% (IQR 44.4-66.7%). There was a moderate level of agreement between content of standard and digital notes (kappa 0.54, 95%CI 0.49-0.60). The quality of the digital note was within the 1 point clinically significant difference for all of the attributes, except for conciseness. Digital notes had a higher frequency of CMS severity elements identified.

CONCLUSION

Digitally generated clinical notes had moderate agreement compared to standard clinical notes and within the one point clinically significant difference except for the conciseness attribute. Digital notes more reliably documented billing components of severity. The use of automated notes should be further explored to evaluate its utility in facilitating documentation of patient encounters.

Overconfidence in Managing Health Concerns: The Dunning-Kruger Effect and Health Literacy

Health literacy is often low within the general population. The Dunning–Kruger effect (DKE) suggests that individuals may experience a cognitive bias in which they overestimate their own knowledge base. This study examines the DKE regarding health literacy and health behaviors. A community sample (n = 504) completed questionnaires measuring objective health literacy, confidence in health knowledge, and health behaviors and medical conditions. Results support the presence of a DKE for health literacy; individuals with low health literacy reported equal or greater confidence in health knowledge than individuals with higher health literacy. Individuals with lower health literacy reported more problematic engagement in health behaviors. Low health literacy can impact engagement in health behavior and effect health outcomes, but individuals may not realize this deficit. Implications for clinical intervention include the need to address cognitive bias and enhance motivation to participate in health literacy interventions.

Opportunities for theory-informed decision science in cancer control

Cancer prevention and control involves navigation of complex clinical decisions, often laden with uncertainty and/or intricate interpersonal dynamics, which have implications for both physical health and quality of life. Cancer decision-making research in recent decades has primarily focused on working to improve the quality of decisions by providing patients with detailed information about their choices and through an increased emphasis in medicine on the importance of shared decision making. This emphasis is reflective of a model of decision making that emphasizes knowledge, options, and deliberative synthesis of information as primary to decision making; yet, decades of research in psychology, decision science, and behavioral economics have taught us that our decisions are not influenced only by our objective knowledge of facts, but by our emotions, by the influence of others, and by biased cognitive processes. We present a conceptual framework for a future of research in decision science and cancer that is informed by decision science theories. Our framework incorporates greater recognition of the interpersonal dynamics of shared decision making, including the biases (including cognitive heuristics and race-based bias) that may affect multiple actors in the decision-making process, and emphasizes study of the interaction between deliberative and affective psychological processes as they relate to decision making. This work should be conducted with an eye toward informing efforts to improve decision making across the cancer care continuum, through interventions that are also informed by theory.

Occurrence and timing of withdrawal of life-sustaining measures in traumatic brain injury patients: a CENTER-TBI study

Background

In patients with severe brain injury, withdrawal of life-sustaining measures (WLSM) is common in intensive care units (ICU). WLSM constitutes a dilemma: instituting WLSM too early could result in death despite the possibility of an acceptable functional outcome, whereas delaying WLSM could unnecessarily burden patients, families, clinicians, and hospital resources. We aimed to describe the occurrence and timing of WLSM, and factors associated with timing of WLSM in European ICUs in patients with traumatic brain injury (TBI).

Methods

The CENTER-TBI Study is a prospective multi-center cohort study. For the current study, patients with traumatic brain injury (TBI) admitted to the ICU and aged 16 or older were included. Occurrence and timing of WLSM were documented. For the analyses, we dichotomized timing of WLSM in early (< 72 h after injury) versus later (≥ 72 h after injury) based on recent guideline recommendations. We assessed factors associated with initiating WLSM early versus later, including geographic region, center, patient, injury, and treatment characteristics with univariable and multivariable (mixed effects) logistic regression.

Results

A total of 2022 patients aged 16 or older were admitted to the ICU. ICU mortality was 13% (n = 267). Of these, 229 (86%) patients died after WLSM, and were included in the analyses. The occurrence of WLSM varied between regions ranging from 0% in Eastern Europe to 96% in Northern Europe. In 51% of the patients, WLSM was early. Patients in the early WLSM group had a lower maximum therapy intensity level (TIL) score than patients in the later WLSM group (median of 5 versus 10) The strongest independent variables associated with early WLSM were one unreactive pupil (odds ratio (OR) 4.0, 95% confidence interval (CI) 1.3–12.4) or two unreactive pupils (OR 5.8, CI 2.6–13.1) compared to two reactive pupils, and an Injury Severity Score (ISS) if over 41 (OR per point above 41 = 1.1, CI 1.0–1.1). Timing of WLSM was not significantly associated with region or center.

Conclusion

WLSM occurs early in half of the patients, mostly in patients with severe TBI affecting brainstem reflexes who were severely injured. We found no regional or center influences in timing of WLSM. Whether WLSM is always appropriate or may contribute to a self-fulfilling prophecy requires further research and argues for reluctance to institute WLSM early in case of any doubt on prognosis.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00134-021-06484-1.

Decision Science Can Inform Clinical Trade-Offs Regarding Cardiotoxic Cancer Treatments

Cancer treatment-related cardiotoxicity (ie, heart failure, coronary artery disease, vascular diseases, arrhythmia) is a growing cancer survivorship concern within oncology practice; heart disease is the leading cause of noncancer death in cancer survivors and surpasses cancer as the leading cause of death for some cancers with higher survival rates. The issue of cardiotoxicity introduces a critical tradeoff that must be acknowledged and reconciled in clinical oncology practice: treating cancer aggressively and effectively in the present vs preventing future cardiotoxicity. Although many cancers must be treated as aggressively as possible, for others, multiple treatment options are available. Yet even when effective and less cardiotoxic treatments are available, they are not always chosen. Wariness to choose equally effective but less cardiotoxic treatment options may result in part from providers' and patients' reliance on "cognitive heuristics," or mental shortcuts that people (including, research shows, medical professionals) use to simplify complex judgments. These heuristics include delay discounting, availability and affect heuristics, and default bias. In the current commentary, we describe relevant research that illuminates how use of heuristics leads to biased medical decision making and translate how this research may apply when the tradeoff between aggressive cancer treatment and preventing future cardiotoxicity is considered. We discuss the implications of these biases in oncology practice, offer potential solutions to reduce bias, and call for future research in this area.

The association between professional stratification and use of online sources: Evidence from the National Dental Practice-Based Research Network

The use of online information sources in most professions is widespread, and well researched. Less understood is how the use of these sources vary across the strata within a single profession, and how question context affects search behaviour. Using the dental profession as a case of a highly stratified discipline, we examine search preferences for sources by professional strata among dentists in a practice-based network. Results show that variation exists in information search behaviour across professional strata of dental clinicians. This study highlights the importance of addressing information literacy across different levels of a profession. Findings also underscore that search behaviour and source preference vary with perceived question relevance.

Transitions from One Electronic Health Record to Another: Challenges, Pitfalls, and Recommendations

OBJECTIVE

We address the challenges of transitioning from one electronic health record (EHR) to another-a near ubiquitous phenomenon in health care. We offer mitigating strategies to reduce unintended consequences, maximize patient safety, and enhance health care delivery.

METHODS

We searched PubMed and other sources to identify articles describing EHR-to-EHR transitions. We combined these references with the authors' extensive experience to construct a conceptual schema and to offer recommendations to facilitate transitions.

RESULTS

Our PubMed query retrieved 1,351 citations: 43 were relevant for full paper review and 18 met the inclusion criterion of focus on EHR-to-EHR transitions. An additional PubMed search yielded 1,014 citations, for which we reviewed 74 full papers and included 5. We supplemented with additional citations for a total of 70 cited. We distinguished 10 domains in the literature that overlap yet present unique and salient opportunities for successful transitions and for problem mitigation.

DISCUSSION

There is scant literature concerning EHR-to-EHR transitions. Identified challenges include financial burdens, personnel resources, patient safety threats from limited access to legacy records, data integrity during migration, cybersecurity, and semantic interoperability. Transition teams must overcome inadequate human infrastructure, technical challenges, security gaps, unrealistic providers' expectations, workflow changes, and insufficient training and support-all factors affecting potential clinician burnout.

CONCLUSION

EHR transitions are remarkably expensive, laborious, personnel devouring, and time consuming. The paucity of references in comparison to the topic's salience reinforces the necessity for this type of review and analysis. Prudent planning may streamline EHR transitions and reduce expenses. Mitigating strategies, such as preservation of legacy data, managing expectations, and hiring short-term specialty consultants can overcome some of the greatest hurdles. A new medical subject headings (MeSH) term for EHR transitions would facilitate further research on this topic.

Cognitive biases in MCDM methods: an embedded filter proposal through sustainable supplier selection problem

Purpose

Expert evaluation is the backbone of the multi-criteria decision-making (MCDM) techniques. The experts make pairwise comparisons between criteria or alternatives in this evaluation. The mainstream research focus on the ambiguity in this process and use fuzzy logic. On the other hand, cognitive biases are the other but scarcely studied challenges to make accurate decisions. The purpose of this paper is to propose pilot filters – as a debiasing strategy – embedded in the MCDM techniques to reduce the effects of framing effect, loss aversion and status quo-type cognitive biases. The applicability of the proposed methodology is shown with analytic hierarchy process-based Technique for Order-Preference by Similarity to Ideal Solution method through a sustainable supplier selection problem.

Design/methodology/approach

The first filter's aim is to reduce framing bias with restructuring the questions. To manipulate the weights of criteria according to the degree of expected status quo and loss aversion biases is the second filter's aim. The second filter is implemented to a sustainable supplier selection problem.

Findings

The comparison of the results of biased and debiased ranking indicates that the best and worst suppliers did not change, but the ranking of suppliers changed. As a result, it is shown that, to obtain more accurate results, employing debiasing strategies is beneficial.

Originality/value

To the best of the author's knowledge, this approach is a novel way to cope with the cognitive biases. Applying this methodology easily to other MCDM techniques will help the decision makers to take more accurate decisions.

Patient decision-making in severe inflammatory bowel disease: the need for improved communication of treatment options and preferences

AIM

Patients with inflammatory bowel disease and their physicians must navigate ever-increasing options for treatment. The aim of this study was to elucidate the key drivers of treatment decision-making in inflammatory bowel disease.

METHODS

We conducted qualitative semi-structured in-person interviews of 20 adult patients undergoing treatment for inflammatory bowel disease at an academic medical centre who either recently initiated biologic therapy or underwent an operation or surgical evaluation. Interviews were audio-recorded, transcribed verbatim, iteratively coded, and discussed to consensus by five researchers. We used thematic analysis to explore factors influencing decision-making.

RESULTS

Four major themes emerged as key drivers of treatment decision-making: perceived clinical state and disease severity, the patient-physician relationship, knowledge, attitudes and beliefs about treatment options, and social isolation and stigma. Patients described experiencing a clinical turning point as the impetus for proceeding with a previously undesired treatment such as infusion medication or surgery. Patients reported delays in care or diagnosis, inadequate communication with their physicians, and lack of control over their disease management. Patients often stated that they considered surgery to be the treatment of last resort, which further compounded the complexity of making treatment decisions.

CONCLUSION

Patients described multiple barriers to making informed and collaborative decisions about treatment, especially when considering surgical options. Our study reveals a need for more comprehensive communication between the patient and their physician about the range of medical and surgical treatment options. We recommend a patient-centred approach toward the decision-making process that accounts for patient decision-making preferences, causes of social stress, and clinical status.

Decision Inertia in Critical Incidents

Abstract. When presented with competing options, critical incident decision makers often struggle to commit to a choice (in particular when all options appear to yield negative consequences). Despite being motivated to take action in disasters, terrorism, major investigations, and complex political interventions, decision makers can become inert, looping between phases of situation assessment, option generation, and option evaluation. This “looping” is functionally redundant when it persists until they have lost the opportunity to take action. We define this as “decision inertia”: the result of a process of (redundant) deliberation over possible options and in the absence of any further useful information. In the context of critical incidents (political, security, military, law enforcement) we have discovered that rather than disengaging and avoiding difficult choices, decision makers are acutely aware of the negative consequences that might arise if they failed to decide (i.e., the incident would escalate). The sensitization to possible future outcomes leads to intense deliberation over possible choices and their consequences and, ultimately, can result in a failure to take any action in time (or at all). We (i) discuss decision inertia as a novel psychological process of redundant deliberation during crises; (ii) define the concept and discuss the emerging studies in support of our tentative hypotheses regarding how the cognitively active process of deliberation can result in complete behavioral inactivity; and (iii) suggest recommendations and interventions for combatting inertia.

Student progress decision-making in programmatic assessment: can we extrapolate from clinical decision-making and jury decision-making?

BACKGROUND

Despite much effort in the development of robustness of information provided by individual assessment events, there is less literature on the aggregation of this information to make progression decisions on individual students. With the development of programmatic assessment, aggregation of information from multiple sources is required, and needs to be completed in a robust manner. The issues raised by this progression decision-making have parallels with similar issues in clinical decision-making and jury decision-making.

MAIN BODY

Clinical decision-making is used to draw parallels with progression decision-making, in particular the need to aggregate information and the considerations to be made when additional information is needed to make robust decisions. In clinical decision-making, diagnoses can be based on screening tests and diagnostic tests, and the balance of sensitivity and specificity can be applied to progression decision-making. There are risks and consequences associated with clinical decisions, and likewise with progression decisions. Both clinical decision-making and progression decision-making can be tough. Tough and complex clinical decisions can be improved by making decisions as a group. The biases associated with decision-making can be amplified or attenuated by group processes, and have similar biases to those seen in clinical and progression decision-making. Jury decision-making is an example of a group making high-stakes decisions when the correct answer is not known, much like progression decision panels. The leadership of both jury and progression panels is important for robust decision-making. Finally, the parallel between a jury's leniency towards the defendant and the failure to fail phenomenon is considered.

CONCLUSION

It is suggested that decisions should be made by appropriately selected decision-making panels; educational institutions should have policies, procedures, and practice documentation related to progression decision-making; panels and panellists should be provided with sufficient information; panels and panellists should work to optimise their information synthesis and reduce bias; panellists should reach decisions by consensus; and that the standard of proof should be that student competence needs to be demonstrated.

Behavioral Investments in the Short Term Fail to Produce a Sunk Cost Effect

A cognitive bias known as the sunk cost effect has been found across a number of contexts. This bias drives the continued investment of time, effort, or money into an endeavor on the basis of prior investments into it. In Studies 1 and 2, we attempted to observe whether this effect occurs for short-term behavioral investments. In both studies, a reverse, or no sunk cost effect was found. In Study 3, we attempted to find an effect using hypothetical scenarios that were analagous to the behavioral investments presented in Study 1. This also failed to reveal an effect. Finally, Study 4 was an attempt to replicate a previously used hypothetical investment scenario; with results this time revealing the effect. A number of explanations for this pattern of results, such as participation and salient physical exertion, are discussed, with the possibility that some short-term behavioral investments are not subject to the sunk cost effect.

Cognitive biases and heuristics in medical decision making: a critical review using a systematic search strategy

BACKGROUND

The role of cognitive biases and heuristics in medical decision making is of growing interest. The purpose of this study was to determine whether studies on cognitive biases and heuristics in medical decision making are based on actual or hypothetical decisions and are conducted with populations that are representative of those who typically make the medical decision; to categorize the types of cognitive biases and heuristics found and whether they are found in patients or in medical personnel; and to critically review the studies based on standard methodological quality criteria.

METHOD

Data sources were original, peer-reviewed, empirical studies on cognitive biases and heuristics in medical decision making found in Ovid Medline, PsycINFO, and the CINAHL databases published in 1980-2013. Predefined exclusion criteria were used to identify 213 studies. During data extraction, information was collected on type of bias or heuristic studied, respondent population, decision type, study type (actual or hypothetical), study method, and study conclusion.

RESULTS

Of the 213 studies analyzed, 164 (77%) were based on hypothetical vignettes, and 175 (82%) were conducted with representative populations. Nineteen types of cognitive biases and heuristics were found. Only 34% of studies (n = 73) investigated medical personnel, and 68% (n = 145) confirmed the presence of a bias or heuristic. Each methodological quality criterion was satisfied by more than 50% of the studies, except for sample size and validated instruments/questions. Limitations are that existing terms were used to inform search terms, and study inclusion criteria focused strictly on decision making.

CONCLUSIONS

Most of the studies on biases and heuristics in medical decision making are based on hypothetical vignettes, raising concerns about applicability of these findings to actual decision making. Biases and heuristics have been underinvestigated in medical personnel compared with patients.