Assessing the impact of colonoscopy complications on use of colonoscopy among primary care physicians and other connected physicians: an observational study of older Americans

Exploiting relationship directionality to enhance statistical modeling of peer-influence across social networks

Risky-prescribing is the excessive or inappropriate prescription of drugs that singly or in combination pose significant risks of adverse health outcomes. In the United States, prescribing of opioids and other "risky" drugs is a national public health concern. We use a novel data framework-a directed network connecting physicians who encounter the same patients in a sequence of visits-to investigate if risky-prescribing diffuses across physicians through a process of peer-influence. Using a shared-patient network of 10 661 Ohio-based physicians constructed from Medicare claims data over 2014-2015, we extract information on the order in which patients encountered physicians to derive a directed patient-sharing network. This enables the novel decomposition of peer-effects of a medical practice such as risky-prescribing into directional (outbound and inbound) and bidirectional (mutual) relationship components. Using this framework, we develop models of peer-effects for contagion in risky-prescribing behavior as well as spillover effects. The latter is measured in terms of adverse health events suspected to be related to risky-prescribing in patients of peer-physicians. Estimated peer-effects were strongest when the patient-sharing relationship was mutual as opposed to directional. Using simulations we confirmed that our modeling and estimation strategies allows simultaneous estimation of each type of peer-effect (mutual and directional) with accuracy and precision. We also show that failing to account for these distinct mechanisms (a form of model mis-specification) produces misleading results, demonstrating the importance of retaining directional information in the construction of physician shared-patient networks. These findings suggest network-based interventions for reducing risky-prescribing.

Evidence for Anchoring Bias During Physician Decision-Making

Introduction

Cognitive biases are hypothesized to influence physician decision-making, but large-scale evidence consistent with their influence is limited. One such bias is anchoring bias, or the focus on a single-often initial-piece of information when making clinical decisions without sufficiently adjusting to later information.

Objective

To examine whether physicians were less likely to test patients with congestive heart failure (CHF) presenting to the emergency department (ED) with shortness of breath (SOB) for pulmonary embolism (PE) when the patient visit reason section, documented in triage before physicians see the patient, mentioned CHF.

Design, Setting, and Participants

In this cross-sectional study of 2011 to 2018 national Veterans Affairs data, patients with CHF presenting with SOB in Veterans Affairs EDs were included in the analysis. Analyses were performed from July 2019 to January 2023.

Exposure

The patient visit reason section, documented in triage before physicians see the patient, mentions CHF.

Main Outcomes and Measures

The main outcomes were testing for PE (D-dimer, computed tomography scan of the chest with contrast, ventilation/perfusion scan, lower-extremity ultrasonography), time to PE testing (among those tested for PE), B-type natriuretic peptide (BNP) testing, acute PE diagnosed in the ED, and acute PE ultimately diagnosed (within 30 days of ED visit).

Results

The present sample included 108 019 patients (mean [SD] age, 71.9 [10.8] years; 2.5% female) with CHF presenting with SOB, 4.1% of whom had mention of CHF in the patient visit reason section of the triage documentation. Overall, 13.2% of patients received PE testing, on average within 76 minutes, 71.4% received BNP testing, 0.23% were diagnosed with acute PE in the ED, and 1.1% were ultimately diagnosed with acute PE. In adjusted analyses, mention of CHF was associated with a 4.6 percentage point (pp) reduction (95% CI, -5.7 to -3.5 pp) in PE testing, 15.5 more minutes (95% CI, 5.7-25.3 minutes) to PE testing, and 6.9 pp (95% CI, 4.3-9.4 pp) more BNP testing. Mention of CHF was associated with a 0.15 pp lower (95% CI, -0.23 to -0.08 pp) likelihood of PE diagnosis in the ED, although no significant association between the mention of CHF and ultimately diagnosed PE was observed (0.06 pp difference; 95% CI, -0.23 to 0.36 pp).

Conclusions and Relevance

In this cross-sectional study among patients with CHF presenting with SOB, physicians were less likely to test for PE when the patient visit reason that was documented before they saw the patient mentioned CHF. Physicians may anchor on such initial information in decision-making, which in this case was associated with delayed workup and diagnosis of PE.

Longitudinal assessment of colonoscopy adverse events in the prospective Cooperative Studies Program no. 380 colorectal cancer screening and surveillance cohort

BACKGROUND AND AIMS

Data are limited regarding colonoscopy risk during long-term, programmatic colorectal cancer screening and follow-up. We aimed to describe adverse events during follow-up in a colonoscopy screening program after the baseline examination and examine factors associated with increased risk.

METHODS

Cooperative Studies Program no. 380 includes 3121 asymptomatic veterans aged 50 to 75 years who underwent screening colonoscopy between 1994 and 1997. Periprocedure adverse events requiring significant intervention were defined as major events (other events were minor) and were tracked during follow-up for at least 10 years. Multivariable odds ratios (ORs) were calculated for factors associated with risk of follow-up adverse events.

RESULTS

Of 3727 follow-up examinations in 1983 participants, adverse events occurred in 105 examinations (2.8%) in 93 individuals, including 22 major and 87 minor events (examinations may have had >1 event). Incidence of major events (per 1000 examinations) remained relatively stable over time, with 6.1 events at examination 2, 4.8 at examination 3, and 7.2 at examination 4. Examinations with major events included 1 perforation, 3 GI bleeds requiring intervention, and 17 cardiopulmonary events. History of prior colonoscopic adverse events was associated with increased risk of events (major or minor) during follow-up (OR, 2.7; 95% confidence interval, 1.6-4.6).

CONCLUSIONS

Long-term programmatic screening and surveillance was safe, as major events were rare during follow-up. However, serious cardiopulmonary events were the most common major events. These results highlight the need for detailed assessments of comorbid conditions during routine clinical practice, which could help inform individual decisions regarding the utility of ongoing colonoscopy follow-up.

Changes in Cancer Screening Rates Following a New Cancer Diagnosis in a Primary Care Patient Panel

IMPORTANCE

Although screenings for breast and colorectal cancer are widely recommended, patient screening rates vary greatly and remain below public health targets, and primary care physicians' (PCPs') counseling and referrals play critical roles in patients' use of cancer screenings. Recent adverse events may influence PCPs' decision-making, but it remains unknown whether cancer screening rates of PCPs' patients change after PCPs are exposed to new cancer diagnoses.

OBJECTIVE

To investigate whether PCPs' exposures to patients with new diagnoses of breast or colorectal cancer were associated with changes in screening rates for other patients subsequently visiting the affected PCPs.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used stacked difference-in-differences analyses of all-payer claims data for New Hampshire and Maine in 2009 to 2015. Participants were PCPs caring for patients. Data analysis was performed from June 2020 to May 2022.

EXPOSURES

New diagnosis of a PCP's patient with breast cancer or colorectal cancer.

MAIN OUTCOMES AND MEASURES

Patients' breast and colorectal cancer screening rates within 1 year of a PCP visit.

RESULTS

The sample included 3158 PCPs (1819 male PCPs [57.6%]) caring for 1 920 189 patients (1 073 408 female patients [55.9%]; mean [SD] age, 41.0 [21.9] years) aged 18 to 64 years. During the study period, 898 PCPs had a patient with a new diagnosis of breast cancer and 370 PCPs had a patient with a new diagnosis of colorectal cancer. In the preexposure period, 68 837 female patients (37.3% of those visiting a PCP) underwent breast cancer screening within 1 year of the visit, and 13 137 patients (10.1% of those visiting a PCP) underwent colorectal cancer screening within 1 year of the visit. For both cancer types, after exposure to a new cancer diagnosis, PCPs' cancer screening rates displayed a rapid, sustained increase. Breast cancer screening rates increased by 4.5 percentage points (95% CI, 3.0-6.1 percentage points; P < .001). Colorectal cancer screening rates increased by 1.3 percentage points (95% CI, 0.3-2.2 percentage points; P = .01). Observed breast cancer screening increases were higher for male PCPs than for female PCPs (3.1 percentage points; 95% CI, 0.4-5.8 percentage points; P = .03).

CONCLUSIONS AND RELEVANCE

This study found significant, sustained increases in cancer screening rates for patients visiting PCPs recently exposed to new breast and colorectal cancer diagnoses. These findings suggest that PCPs may update practice patterns on the basis of recent patient diagnoses. Future work should assess whether salient cues to PCPs about patient diagnoses when clinically appropriate can improve screening practices.

Heuristics in the delivery room

[Figure: see text].

The Influence of the Availability Heuristic on Physicians in the Emergency Department

STUDY OBJECTIVE

Heuristics, or rules of thumb, are hypothesized to influence the care physicians deliver. One such heuristic is the availability heuristic, under which assessments of an event's likelihood are affected by how easily the event comes to mind. We examined whether the availability heuristic influences physician testing in a common, high-risk clinical scenario: assessing patients with shortness of breath for the risk of pulmonary embolism.

METHODS

We performed an event study from 2011 to 2018 of emergency physicians caring for patients presenting with shortness of breath to 104 Veterans Affairs (VA) hospitals. Our measures were physician rates of pulmonary embolism testing (D-dimer and/or computed tomography scan) for subsequent patients after having a patient visit with a pulmonary embolism discharge diagnosis, hypothesizing that physician rates of pulmonary embolism testing would increase after having a recent patient visit with a pulmonary embolism diagnosis due to the availability heuristic.

RESULTS

The sample included 7,370 emergency physicians who had 416,720 patient visits for shortness of breath. The mean rate of pulmonary embolism testing was 9.0%. For physicians who had a recent patient visit with a pulmonary embolism diagnosis, their rate of pulmonary embolism testing for subsequent patients increased by 1.4 percentage points (95% confidence interval 0.42 to 2.34) in the 10 days after, which is approximately 15% relative to the mean rate of pulmonary embolism testing. We failed to find statistically significant changes in rates of pulmonary embolism testing in the subsequent 50 days following these first 10 days.

CONCLUSION

After having a recent patient visit with a pulmonary embolism diagnosis, physicians increase their rates of pulmonary embolism testing for subsequent patients, but this increase does not persist. These results provide large-scale evidence that the availability heuristic may play a role in complex testing decisions.

DNA methylation detection methods used in colorectal cancer

Colorectal cancer (CRC) remains a major contributor to the number of cancer-related deaths that occur annually worldwide. With the development of molecular biology methods, an increasing number of molecular biomarkers have been identified and investigated. CRC is believed to result from an accumulation of epigenetic changes, and detecting aberrant DNA methylation patterns is useful for both the early diagnosis and prognosis of CRC. Numerous studies are focusing on the development of DNA methylation detection methods or DNA methylation panels. Thus, this review will discuss the commonly used techniques and technologies to evaluate DNA methylation, their merits and deficiencies as well as the prospects for new methods.