‘Cognitive biases plus’: covert subverters of healthcare evidence

Cross-sectional survey and Bayesian network model analysis of traditional Chinese medicine in Austria: investigating public awareness, usage determinants and perception of scientific support

OBJECTIVES

Despite the paucity of evidence verifying its efficacy and safety, traditional Chinese medicine (TCM) is expanding in popularity and political support. Decisions to include TCM diagnoses in the International Classification of Diseases 11th Revision and campaigns to integrate TCM into national healthcare systems have occurred while public perception and usage of TCM, especially in Europe, remains undetermined. Accordingly, this study investigates TCM's popularity, usage and perceived scientific support, as well as its relationship to homeopathy and vaccinations.

DESIGN/SETTING

We performed a cross-sectional survey of the Austrian population. Participants were either recruited on the street (in-person) or online (web-link) via a popular Austrian newspaper.

PARTICIPANTS

1382 individuals completed our survey. The sample was poststratified according to data derived from Austria's Federal Statistical Office.

OUTCOME MEASURES

Associations between sociodemographic factors, opinion towards TCM and usage of complementary medicine (CAM) were investigated using a Bayesian graphical model.

RESULTS

Within our poststratified sample, TCM was broadly known (89.9% of women, 90.6% of men), with 58.9% of women and 39.5% of men using TCM between 2016 and 2019. Moreover, 66.4% of women and 49.7% of men agreed with TCM being supported by science. We found a positive relationship between perceived scientific support for TCM and trust in TCM-certified medical doctors (ρ=0.59, 95% CI 0.46 to 0.73). Moreover, perceived scientific support for TCM was negatively correlated with proclivity to get vaccinated (ρ=-0.26, 95% CI -0.43 to -0.08). Additionally, our network model yielded associations between TCM-related, homeopathy-related and vaccination-related variables.

CONCLUSIONS

TCM is widely known within the Austrian general population and used by a substantial proportion. However, a disparity exists between the commonly held public perception that TCM is scientific and findings from evidence-based studies. Emphasis should be placed on supporting the distribution of unbiased, science-driven information.

Error traps in pediatric difficult airway management

Difficult airway management in children is associated with significant morbidity. This narrative review on error traps in airway management aims to highlight the common pitfalls and proposes solutions to optimize best practices for pediatric difficult airway management. We have categorized common errors of pediatric difficult airway management into three main error traps: preparation, performance, and proficiency, and present potential strategies to improve patient safety and successful tracheal intubation in infants and children with difficult airways.

The iatrogenic opioid crisis: An example of 'institutional corruption of pharmaceuticals'?

RATIONALE

Prescribed opioids are major contributors to the international public health opioid crisis. Such widespread iatrogenic harms usually result from collective decision failures of healthcare organizations rather than solely of individual organizations or professionals. Findings from a system-wide safety analysis of the iatrogenic opioid crisis that includes roles of pertinent healthcare organizations may help avoid or mitigate similar future iatrogenic consequences. In this retrospective exploratory study, we report such an analysis.

METHODS

The study population encompassed the entire age spectrum and included those in whom opioids prescribed for chronic pain (unrelated to malignancy) were associated with death or morbidity. Root cause analysis, incorporating recent suggestions for improvement, was used to identify possible contributory factors from the literature. Based on their mandated roles and potential influences to prevent or mitigate the iatrogenic crisis, relevant organizations were grouped and stratified from most to least influential.

RESULTS

The analysis identified a chain of multiple interrelated causal factors within and between organizations. The most influential organizations were pharmaceutical, political, and drug regulatory; next: experts and their related societies, and publications. Less influential: accreditation, professional licensing and regulatory, academic and healthcare funding bodies. Collectively, their views and decisions influenced prescribing practices of frontline healthcare professionals and advocacy groups. Financial associations between pharmaceutical and most other organizations/groups were common. Ultimately, patients were adversely affected. There was a complex association with psychosocial variables.

LIMITATIONS

The analysis suggests associations not causality.

CONCLUSION

The iatrogenic crisis has multiple intricately linked roots. The major catalyst: pervasive pharma-linked financial conflicts of interest (CoIs) involving most other healthcare organizations. These extensive financial CoIs were likely triggers for a cascade of erroneous decisions and actions that adversely affected patients. The actions and decisions of pharma ranged from unethical to illegal. The iatrogenic opioid crisis may exemplify 'institutional corruption of pharmaceuticals'.

Disclosure of Interests and Management of Conflicts of Interest in Clinical Guidelines and Guidance Statements: Methods From the Clinical Guidelines Committee of the American College of Physicians

One of the hallmarks of a trustworthy clinical guideline or guidance statement is a comprehensive process for disclosure of interests (DOI) and management of conflicts of interest (COIs). The American College of Physicians (ACP) Clinical Guidelines Committee (CGC) aims to disclose all health care-related interests and manage conflicts in a manner that is transparent, proportional, and consistent. Any person involved in the development of an ACP clinical guideline or guidance statement must disclose all financial and intellectual interests related to health care from the previous 3 years. Persons complete disclosures at the start of their participation and are required to update them over the course of their involvement with the CGC, including before each CGC meeting. A DOI-COI Review and Management Panel reviews the disclosures; flags potential conflicts; grades the COI as low-, moderate-, or high-level; and manages the person's participation accordingly. A high-level COI results in recusal from authorship, voting, and all committee discussions. Participants with a moderate-level COI are recused from authorship and voting for clinically relevant topics but may participate in all discussions. A low-level COI results in no role restrictions. All disclosures and COI management decisions are publicly reported.

Two's company, is three a crowd? Ethical cognition in decision making and the role of industry third parties in pediatric diabetes care

Families of children with diabetes increasingly obtain health information from a variety of sources. Doctor-patient relationships have accordingly become more fluid and dynamic with input from other parties. These outside parties include representatives from the diabetes health care industry-industry third parties (ITPs). This review is an exploration of the ethical principles and cognitive processes involved when doctors and patients negotiate around health care practices and the role of ITPs in that dialogue. Ethical principles of conflicts of interest, beneficence (act in the best interests of the patient), non-maleficence (act so as to do no harm) and justice (act so as to allocate resources fairly or justly) are relevant considerations. Reflexive and analytic thinking and various cognitive biases also play a significant part in clinical decision making. A complex case example is analyzed to highlight a process of ethical cognition in decision making to ensure high-value care and optimal patient outcomes.

Randomized clinical trials and observational studies in the assessment of drug safety

Randomized clinical trials are considered as the preferred design to assess the potential causal relationships between drugs or other medical interventions and intended effects. For this reason, randomized clinical trials are generally the basis of development programs in the life cycle of drugs and the cornerstone of evidence-based medicine. Instead, randomized clinical trials are not the design of choice for the detection and assessment of rare, delayed and/or unexpected effects related to drug safety. Moreover, the highly homogeneous populations resulting from restrictive eligibility criteria make randomized clinical trials inappropriate to describe comprehensively the safety profile of drugs. In that context, observational studies have a key added value when evaluating the benefit-risk balance of the drugs. However, observational studies are more prone to bias than randomized clinical trials and they have to be designed, conducted and reported judiciously. In this article, we discuss the strengths and limitations of randomized clinical trials and of observational studies, more particularly regarding their contribution to the knowledge of medicines' safety profile. In addition, we present general recommendations for the sensible use of observational data.

Gating the holes in the Swiss cheese (part I): Expanding professor Reason's model for patient safety

INTRODUCTION

Although patient safety has improved steadily, harm remains a substantial global challenge. Additionally, safety needs to be ensured not only in hospitals but also across the continuum of care. Better understanding of the complex cognitive factors influencing health care-related decisions and organizational cultures could lead to more rational approaches, and thereby to further improvement.

HYPOTHESIS

A model integrating the concepts underlying Reason's Swiss cheese theory and the cognitive-affective biases plus cascade could advance the understanding of cognitive-affective processes that underlie decisions and organizational cultures across the continuum of care.

METHODS

Thematic analysis, qualitative information from several sources being used to support argumentation.

DISCUSSION

Complex covert cognitive phenomena underlie decisions influencing health care. In the integrated model, the Swiss cheese slices represent dynamic cognitive-affective (mental) gates: Reason's successive layers of defence. Like firewalls and antivirus programs, cognitive-affective gates normally allow the passage of rational decisions but block or counter unsounds ones. Gates can be breached (ie, holes created) at one or more levels of organizations, teams, and individuals, by (1) any element of cognitive-affective biases plus (conflicts of interest and cognitive biases being the best studied) and (2) other potential error-provoking factors. Conversely, flawed decisions can be blocked and consequences minimized; for example, by addressing cognitive biases plus and error-provoking factors, and being constantly mindful. Informed shared decision making is a neglected but critical layer of defence (cognitive-affective gate). The integrated model can be custom tailored to specific situations, and the underlying principles applied to all methods for improving safety. The model may also provide a framework for developing and evaluating strategies to optimize organizational cultures and decisions.

LIMITATIONS

The concept is abstract, the model is virtual, and the best supportive evidence is qualitative and indirect.

CONCLUSIONS

The proposed model may help enhance rational decision making across the continuum of care, thereby improving patient safety globally.

Mitigating Evidentiary Bias in Planning and Policy-Making Comment on "Reflective Practice: How the World Bank Explored Its Own Biases?"

The field of cognitive psychology has increasingly provided scientific insights to explore how humans are subject to unconscious sources of evidentiary bias, leading to errors that can affect judgement and decision-making. Increasingly these insights are being applied outside the realm of individual decision-making to the collective arena of policy-making as well. A recent editorial in this journal has particularly lauded the work of the World Bank for undertaking an open and critical reflection on sources of unconscious bias in its own expert staff that could undermine achievement of its key goals. The World Bank case indeed serves as a remarkable case of a global policy-making agency making its own critical reflections transparent for all to see. Yet the recognition that humans are prone to cognitive errors has been known for centuries, and the scientific exploration of such biases provided by cognitive psychology is now well-established. What still remains to be developed, however, is a widespread body of work that can inform efforts to institutionalise strategies to mitigate the multiple sources and forms of evidentiary bias arising within administrative and policy-making environments. Addressing this gap will require a programme of conceptual and empirical work that supports robust development and evaluation of institutional bias mitigation strategies. The cognitive sciences provides a scientific basis on which to proceed, but a critical priority will now be the application of that science to improve policy-making within those agencies taking responsibility for social welfare and development programmes.

A 'reluctant' critical review: 'Manual for evidence-based clinical practice (2015)'

BACKGROUND

The Users' Guides to the Medical Literature Manual has been a major influence on the teaching and practice of health care globally.

METHODS

The 3rd edition of the multi-authored Manual was reviewed using the principles outlined in Evidence-based Medicine (EBM) texts. One 'clinical scenario' was selected for critical appraisal, as were several chapters; objectivity was enhanced by citing references to support opinions. RESULTS (SUMMARY OF THE APPRAISAL): (1) Strengths: Clinical pearls, too numerous to list.

EXAMPLES

(i) evidence is never enough to drive clinical decision making; (ii) do not rush to adopt new interventions; and (iii) question efficacy data based only on surrogate markers. (2) Weaknesses: The Manual shares shortcomings of textbooks discussed by Straus et al.: (i) references may not be current, important ones may be excluded and citations may be selective; (ii) often, opinion-based; and (iii) delays between revisions. (3) Notable omissions: Little or no discussion of: (i) important segments of the population: those <18 years of age, >65 years of age and those with multimorbidity; (ii) surgical disciplines; (iii) Greenhalgh et al.'s essay on EBM; (iv) alternate views on the hierarchy of evidence; and (vi) critical thinking. (4) Additional issues: (i) Omission of important references on dabigatran (clinical scenario: chapter 13.1); (ii) authors' advice (Chapter 13.3) to 'bypass the discussion section of published research'; and (iii) the advocacy of pre-appraised sources of evidence and network meta-analysis without warnings about limitations, are critiqued.

CONCLUSION

The Manual has several clinical pearls but readers should also be aware of shortcomings.