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Poco LC, Balasubramanian I, Chaudhry I, Malhotra C. Awareness of Disease Incurability Moderates the Association between Patients' Health Status and Their Treatment Preferences. Med Decis Making 2025; 45:74-85. [PMID: 39520110 DOI: 10.1177/0272989x241293716] [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: 11/16/2024]
Abstract
BACKGROUND With advancing illness, some patients with heart failure (HF) opt to receive life-extending treatments despite their high costs, while others choose to forgo these treatments, emphasizing cost containment. We examined the association between patients' health status and their preferences for treatment cost containment versus life extension and whether their patients' awareness of disease incurability moderated this association. METHODS In a prospective cohort of patients (N = 231) with advanced HF in Singapore, we assessed patients' awareness of disease incurability, health status, and treatment preferences every 4 mo for up to 4 y (up to 13 surveys). Using random effects multinomial logistic regression models, we assessed whether patients' awareness of disease incurability moderated the association between their health status and treatment preferences. RESULTS About half of the patients in our study lacked awareness of HF's incurability. Results from regression analyses showed that patients with better health status, as indicated by lower distress scores (odds ratio [OR] [95% confidence interval {CI}]: 0.862 [0.754, 0.985]) and greater physical well-being (1.12 [1.03, 1.21]); and who lacked awareness of their disease's incurability were more likely to prefer higher cost containment/minimal life extension treatments compared with lower cost containment/maximal life extension. CONCLUSIONS This study underscores the significance of patients' awareness in disease incurability in shaping the relationship between their health status and treatment preferences. Our findings emphasize the need to incorporate illness education during goals-of-care conversations with patients and the importance of revisiting these conversations frequently to accommodate changing treatment preferences. HIGHLIGHTS The health status of patients with advanced heart failure was associated with their treatment preferences.Patients whose health status improved and who lacked awareness of their disease's incurability were more likely to prefer higher cost containment/minimal life extension treatments.
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Affiliation(s)
| | | | - Isha Chaudhry
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore
| | - Chetna Malhotra
- Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore
- Health Services and Systems Research, Duke-NUS Medical School, Singapore
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Meguerdichian MJ, Trottier DG, Campbell-Taylor K, Bentley S, Bryant K, Kolbe M, Grant V, Cheng A. When common cognitive biases impact debriefing conversations. Adv Simul (Lond) 2024; 9:48. [PMID: 39695901 DOI: 10.1186/s41077-024-00324-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2024] [Accepted: 11/23/2024] [Indexed: 12/20/2024] Open
Abstract
Healthcare debriefing is a cognitively demanding conversation after a simulation or clinical experience that promotes reflection, underpinned by psychological safety and attention to learner needs. The process of debriefing requires mental processing that engages both "fast" or unconscious thinking and "slow" intentional thinking to be able to navigate the conversation. "Fast" thinking has the potential to surface cognitive biases that impact reflection and may negatively influence debriefer behaviors, debriefing strategies, and debriefing foundations. As a result, negative cognitive biases risk undermining learning outcomes from debriefing conversations. As the use of healthcare simulation is expanding, the need for faculty development specific to the roles bias plays is imperative. In this article, we hope to build awareness about common cognitive biases that may present in debriefing conversations so debriefers have the chance to begin the hard work of identifying and attending to their potential detrimental impacts.
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Affiliation(s)
- Michael J Meguerdichian
- Institute for Simulation and Advanced Learning, 1400 Pelham Parkway S, Bronx, NY, 10461, USA.
- Department of Emergency Medicine, NYC Health+Hospitals: Harlem Hospital Center, 506 Malcolm X Blvd, New York, NY, USA.
| | - Dana George Trottier
- Institute for Simulation and Advanced Learning, 1400 Pelham Parkway S, Bronx, NY, 10461, USA
| | | | - Suzanne Bentley
- Icahn School of Medicine at Mt. Sinai, Gustave L. Levy Pl, Elmhurst Hospital Center, 79-01 Broadway, Queens, New York, NY, 10029, USA
| | - Kellie Bryant
- National League of Nursing, 2600 Virginia Ave NW, Washington D.C, 20037, USA
| | - Michaela Kolbe
- Simulation Centre, University Hospital Zurich, Zurich, Switzerland
| | - Vincent Grant
- eSim Provincial Simulation Program for Alberta Health Services, Alberta, Canada
| | - Adam Cheng
- Department of Pediatrics and Emergency Medicine, University of Calgary, 28 Oki Drive NW, Calgary, Canada
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Shuman S, Berhane T, Madden D, Larson R, Jacobs A, Chiofalo J, Vangeepuram N. COVID-19 Vaccine Effectiveness and Barriers to Vaccination: Comparing Perceptions Based on Vaccination Status. J Racial Ethn Health Disparities 2024:10.1007/s40615-024-02243-2. [PMID: 39636356 DOI: 10.1007/s40615-024-02243-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2024] [Revised: 11/17/2024] [Accepted: 11/20/2024] [Indexed: 12/07/2024]
Abstract
New York City (NYC) was the first epicenter of the COVID-19 pandemic in the USA. Despite the availability of COVID-19 vaccines by 2021, vaccination rates varied among racial and ethnic groups, further exacerbating COVID-19-related health disparities. This study explores the relationship between vaccination status and perspectives on COVID-19-related topics among racially and ethnically diverse NYC residents. The New York Community Engagement Alliance Against COVID-19 Disparities (NYCEAL) conducted focus groups with NYC residents to explore their perceptions about vaccine effectiveness and barriers to vaccination that may impact vaccine decision-making. We conducted seven focus groups between December 2021 and April 2022 in English and Spanish with individuals grouped based on vaccination status: (1) those vaccinated when vaccines first became available, (2) those vaccinated after mandates were announced, and (3) those who remained unvaccinated. Transcripts were initially analyzed using a priori and in vivo codes, and the team utilized framework analysis to examine similarities and differences across groups. Emerging themes centered on trust in science, perceived vaccine effectiveness, and the evolution of people's COVID-19-related perspectives, experiences, and behaviors over time. Although there were distinctions between groups on concepts like trust in science and perceived vaccine effectiveness, people's cognitive biases seemed to affect their perceptions but not necessarily their (vaccine-related) behaviors. Findings from this study may help public health professionals understand vaccine decision-making from the perspective of a diverse set of New Yorkers for use during future epidemics.
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Affiliation(s)
- Saskia Shuman
- The Institute for Family Health, 2006 Madison Avenue, New York, NY, 10035, USA.
| | - Timnit Berhane
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Devin Madden
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rita Larson
- NYU Grossman School of Medicine, New York, NY, USA
| | - Ariel Jacobs
- The Institute for Family Health, 2006 Madison Avenue, New York, NY, 10035, USA
| | - Jacqueline Chiofalo
- The Institute for Family Health, 2006 Madison Avenue, New York, NY, 10035, USA
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Weber S, Wyszynski M, Godefroid M, Plattfaut R, Niehaves B. How do medical professionals make sense (or not) of AI? A social-media-based computational grounded theory study and an online survey. Comput Struct Biotechnol J 2024; 24:146-159. [PMID: 38434249 PMCID: PMC10904922 DOI: 10.1016/j.csbj.2024.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 02/14/2024] [Accepted: 02/14/2024] [Indexed: 03/05/2024] Open
Abstract
To investigate opinions and attitudes of medical professionals towards adopting AI-enabled healthcare technologies in their daily business, we used a mixed-methods approach. Study 1 employed a qualitative computational grounded theory approach analyzing 181 Reddit threads in the several subreddits of r/medicine. By utilizing an unsupervised machine learning clustering method, we identified three key themes: (1) consequences of AI, (2) physician-AI relationship, and (3) a proposed way forward. In particular Reddit posts related to the first two themes indicated that the medical professionals' fear of being replaced by AI and skepticism toward AI played a major role in the argumentations. Moreover, the results suggest that this fear is driven by little or moderate knowledge about AI. Posts related to the third theme focused on factual discussions about how AI and medicine have to be designed to become broadly adopted in health care. Study 2 quantitatively examined the relationship between the fear of AI, knowledge about AI, and medical professionals' intention to use AI-enabled technologies in more detail. Results based on a sample of 223 medical professionals who participated in the online survey revealed that the intention to use AI technologies increases with increasing knowledge about AI and that this effect is moderated by the fear of being replaced by AI.
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Affiliation(s)
- Sebastian Weber
- University of Bremen, Digital Public, Bibliothekstr. 1, 28359 Bremen, Germany
| | - Marc Wyszynski
- University of Bremen, Digital Public, Bibliothekstr. 1, 28359 Bremen, Germany
| | - Marie Godefroid
- University of Siegen, Information Systems, Kohlbettstr. 15, 57072 Siegen, Germany
| | - Ralf Plattfaut
- University of Duisburg-Essen, Information Systems and Transformation Management, Universitätsstr. 9, 45141 Essen, Germany
| | - Bjoern Niehaves
- University of Bremen, Digital Public, Bibliothekstr. 1, 28359 Bremen, Germany
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Hartjes MG, Richir MC, Cazaubon Y, Donker EM, van Leeuwen E, Likic R, Pers YM, Piët JD, De Ponti F, Raasch W, van Rosse F, Rychlícková J, Sanz EJ, Schwaninger M, Wallerstedt SM, de Vries TPGM, van Agtmael MA, Tichelaar J. Enhancing therapeutic reasoning: key insights and recommendations for education in prescribing. BMC MEDICAL EDUCATION 2024; 24:1360. [PMID: 39587582 PMCID: PMC11590475 DOI: 10.1186/s12909-024-06310-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2024] [Accepted: 11/05/2024] [Indexed: 11/27/2024]
Abstract
BACKGROUND Despite efforts to improve undergraduate clinical pharmacology & therapeutics (CPT) education, prescribing errors are still made regularly. To improve CPT education and daily prescribing, it is crucial to understand how therapeutic reasoning works. Therefore, the aim of this study was to gain insight into the therapeutic reasoning process. METHODS A narrative literature review has been performed for literature on cognitive psychology and diagnostic and therapeutic reasoning. RESULTS Based on these insights, The European Model of Therapeutic Reasoning has been developed, building upon earlier models and insights from cognitive psychology. In this model, it can be assumed that when a diagnosis is made, a primary, automatic response as to what to prescribe arises based on pattern recognition via therapy scripts (type 1 thinking). At some point, this response may be evaluated by the reflective mind (using metacognition). If it is found to be incorrect or incomplete, an alternative response must be formulated through a slower, more analytical and deliberative process, known as type 2 thinking. Metacognition monitors the reasoning process and helps a person to form new therapy scripts after they have chosen an effective therapy. Experienced physicians have more and richer therapy scripts, mostly based on experience and enabling conditions, instead of textbook knowledge, and therefore their type 1 response is more often correct. CONCLUSION Because of the important role of metacognition in therapeutic reasoning, more attention should be paid to metacognition in CPT education. Both trainees and teachers should be aware of the possibility to monitor and influence these cognitive processes. Further research is required to investigate the applicability of these insights and the adaptability of educational approaches to therapeutic reasoning.
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Affiliation(s)
- Mariëlle G Hartjes
- Department of Internal Medicine, Unit Pharmacotherapy, Amsterdam UMC, Vrije Universiteit, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
- Research and Expertise Centre in Pharmacotherapy Education (RECIPE), De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
- Interprofessional Collaboration and Medication Safety, Faculty of Health, Sports and Social Work, InHolland University of Applied Sciences, Pina Bauschplein 4, 1095PN, Amsterdam, The Netherlands.
| | - Milan C Richir
- Department of Internal Medicine, Unit Pharmacotherapy, Amsterdam UMC, Vrije Universiteit, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
- Research and Expertise Centre in Pharmacotherapy Education (RECIPE), De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Yoann Cazaubon
- Department of Pharmacology, Montpellier University Hospital, Avenue du Doyen Gaston Giraud, 34090, Montpellier, France
- Pathogenesis and Control of Chronic and Emerging Infections (PCCEI), INSERM, University Montpellier, 34090, Montpellier, France
| | - Erik M Donker
- Department of Internal Medicine, Unit Pharmacotherapy, Amsterdam UMC, Vrije Universiteit, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
- Research and Expertise Centre in Pharmacotherapy Education (RECIPE), De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Ellen van Leeuwen
- Department of Fundamental and Applied Medical Sciences, Unit of Clinical Pharmacology, Ghent University, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Robert Likic
- Unit of Clinical Pharmacology, Department of Internal Medicine, University Hospital Centre Zagreb and University of Zagreb School of Medicine, 12 Kišpatićeva St, 10 000, Zagreb, Croatia
| | - Yves-Marie Pers
- IRMB, University Montpellier, INSERM, CHU Montpellier, Montpellier, France
- Clinical Immunology and Osteoarticular Diseases Therapeutic Unit, Lapeyronie University Hospital, Montpellier, France
| | - Joost D Piët
- Department of Internal Medicine, Unit Pharmacotherapy, Amsterdam UMC, Vrije Universiteit, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
- Research and Expertise Centre in Pharmacotherapy Education (RECIPE), De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Fabrizio De Ponti
- Department of Medical and Surgical Sciences, Pharmacology Unit, Alma Mater Studiorum, University of Bologna, Via Zamboni 33, 40126, Bologna, Italy
| | - Walter Raasch
- Institute of Experimental and Clinical Pharmacology and Toxicology, University of Lübeck, Lübeck, Germany
| | - Floor van Rosse
- Department of Hospital Pharmacy, University Medical Center Rotterdam, MC, Rotterdam, The Netherlands
| | - Jitka Rychlícková
- Department of Pharmacology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Emilio J Sanz
- School of Health Science, Universidad de La Laguna, and Hospital Universitario de Canarias (SCS), Santa Cruz de Tenerife, Calle Padre Herrera, S/N, 38200, La Laguna Tenerife, Spain
| | - Markus Schwaninger
- Institute of Experimental and Clinical Pharmacology and Toxicology, University of Lübeck, Lübeck, Germany
| | - Susanna M Wallerstedt
- Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Theo P G M de Vries
- Department of Internal Medicine, Unit Pharmacotherapy, Amsterdam UMC, Vrije Universiteit, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
- Research and Expertise Centre in Pharmacotherapy Education (RECIPE), De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Michiel A van Agtmael
- Department of Internal Medicine, Unit Pharmacotherapy, Amsterdam UMC, Vrije Universiteit, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
- Research and Expertise Centre in Pharmacotherapy Education (RECIPE), De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Jelle Tichelaar
- Department of Internal Medicine, Unit Pharmacotherapy, Amsterdam UMC, Vrije Universiteit, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
- Research and Expertise Centre in Pharmacotherapy Education (RECIPE), De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
- Interprofessional Collaboration and Medication Safety, Faculty of Health, Sports and Social Work, InHolland University of Applied Sciences, Pina Bauschplein 4, 1095PN, Amsterdam, The Netherlands
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Baird TA, Previtera M, Brady S, Wright DR, Trout AT, Hayatghaibi SE. Communicating Risk in Imaging: A Scoping Review of Risk Presentation in Patient Decision Aids. J Am Coll Radiol 2024:S1546-1440(24)00839-1. [PMID: 39426648 DOI: 10.1016/j.jacr.2024.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 05/23/2024] [Accepted: 05/28/2024] [Indexed: 10/21/2024]
Abstract
PURPOSE Best practices exist for communicating medical information to patients, but there is less emphasis on methods to communicate risks, especially in medical imaging. The authors conducted a scoping review of patient decision aids in medical imaging and characterized the presentation methods of imaging risks. METHODS Embase, MEDLINE, CINAHL, and PsychINFO were searched to identify studies involving patient decision aids used in diagnostic imaging that communicated the risks. Study characteristics included the number and types of risks included, as well as the presentation type and how the probability of risks were communicated. RESULTS The final study included 46 articles encompassing 27 distinct patient decision aids. Mammography was the most common imaging scenario (22 of 46), followed by lung cancer screening (18 of 46), traumatic brain injury (5 of 46), and urolithiasis (1 of 46). All patient decision aids included risks associated with imaging, but the number of risk types varied from two to nine (mean, 4 ± 2). Twelve risks were identified across the 27 decision aids, but no single study included all risks. Overall, most risks (65%) were communicated with text, and the presentation mode varied by type of risk. False-positive risks were most commonly communicated using a visual format, whereas radiation risk was most commonly communicated using text format. CONCLUSIONS There was no consistent manner of communicating risk to patients, and visual methods such as icon arrays were not consistently used. The variability of both included risks and the risk presentation modes in the patient decision aids may affect decision making, especially among patients and caregivers with lower health literacy and numeracy.
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Affiliation(s)
- Trey A Baird
- College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | | | - Samuel Brady
- College of Medicine, University of Cincinnati, Cincinnati, Ohio; Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Davene R Wright
- Division of Child Health Research and Policy, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Andrew T Trout
- College of Medicine, University of Cincinnati, Cincinnati, Ohio; Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Director of Clinical Research, Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Shireen E Hayatghaibi
- College of Medicine, University of Cincinnati, Cincinnati, Ohio; Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
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Hart JL, Malik L, Li C, Summer A, Ogunduyile L, Steingrub J, Lo B, Zlatev J, White DB. Clinicians' Use of Choice Framing in ICU Family Meetings. Crit Care Med 2024; 52:1533-1542. [PMID: 38912880 DOI: 10.1097/ccm.0000000000006360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/25/2024]
Abstract
OBJECTIVES To quantify the frequency and patterns of clinicians' use of choice frames when discussing preference-sensitive care with surrogate decision-makers in the ICU. DESIGN Secondary sequential content analysis. SETTING One hundred one audio-recorded and transcribed conferences between surrogates and clinicians of incapacitated, critically ill adults from a prospective, multicenter cohort study. SUBJECTS Surrogate decision-makers and clinicians. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Four coders identified preference-sensitive decision episodes addressed in the meetings, including topics such as mechanical ventilation, renal replacement, and overall goals of care. Prior critical care literature provided specific topics identified as preference-sensitive specific to the critical care context. Coders then examined each decision episode for the types of choice frames used by clinicians. The choice frames were selected a priori based on decision science literature. In total, there were 202 decision episodes across the 101 transcripts, with 20.3% of the decision episodes discussing mechanical ventilation, 19.3% overall goals of care, 14.4% renal replacement therapy, 14.4% post-discharge care (i.e., discharge location such as a skilled nursing facility), and the remaining 32.1% other topics. Clinicians used default framing, in which an option is presented that will be carried out if another option is not actively chosen, more frequently than any other choice frame (127 or 62.9% of decision episodes). Clinicians presented a polar interrogative, or a "yes or no question" to accept or reject a specific care choice, in 43 (21.3%) decision episodes. Clinicians more frequently presented options emphasizing both potential losses and gains rather than either in isolation. CONCLUSIONS Clinicians frequently use default framing and polar questions when discussing preference-sensitive choices with surrogate decision-makers, which are known to be powerful nudges. Future work should focus on designing interventions promoting the informed use of these and the other most common choice frames used by practicing clinicians.
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Affiliation(s)
- Joanna L Hart
- Palliative and Advanced Illness Research Center, University of Pennsylvania, Philadelphia, PA
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania, Philadelphia, PA
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA
| | - Leena Malik
- Palliative and Advanced Illness Research Center, University of Pennsylvania, Philadelphia, PA
| | - Carrie Li
- Department of Neurology, Massachusetts General Hospital and Brigham Women's Hospital, Harvard University, Boston, MA
| | - Amy Summer
- Palliative and Advanced Illness Research Center, University of Pennsylvania, Philadelphia, PA
| | - Lon Ogunduyile
- Palliative and Advanced Illness Research Center, University of Pennsylvania, Philadelphia, PA
| | - Jay Steingrub
- University of Massachusetts Chan Medical School-Baystate, Springfield, MA
| | - Bernard Lo
- Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Julian Zlatev
- Department of Business Administration, Harvard Business School, Boston, MA
| | - Douglas B White
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
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Peinado S, O'Donoghue AC, Betts KR, Paquin RS, Giombi K, Arnold JE, Kelly BJ, Davis C. Experimental Study of the Promotional Implications of Proprietary Prescription Drug Names. Ther Innov Regul Sci 2024:10.1007/s43441-024-00704-8. [PMID: 39341979 DOI: 10.1007/s43441-024-00704-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 09/20/2024] [Indexed: 10/01/2024]
Abstract
BACKGROUND The meaning and characteristics embedded in proprietary drug names have the potential to affect name recall, perceptions of drug benefits and risks, and attitudes toward a drug. In this study, we examined: (1) whether names that reference the drug's medical indication affect consumers' and primary care physicians' (PCPs') perceptions of the drug and (2) whether names that overstate the drug's efficacy affect consumers' and PCPs' perceptions of the drug. METHODS We conducted an online experiment with 455 PCPs and 450 consumers to test the effects of fictitious proprietary prescription drug names. Participants were randomized to view one neutral drug name, one name that overstated the drug's efficacy, and five names that referenced the drug's medical indication. RESULTS Names that referenced the drug's medical indication and names that overstated the drug's benefit both influenced perceptions of efficacy and risk compared to neutral names. For several outcomes, names evoking medical indications had similar effects to those designed to overstate the drug's efficacy. The patterns of effects were similar for PCPs and consumers. CONCLUSION Findings suggest drug names alone can be sufficient to produce attitudes and risk and benefit perceptions about drugs, even in the absence of any information beyond the drug's medical indication.
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Affiliation(s)
- Susana Peinado
- RTI International, 3040 E. Cornwallis Road, PO Box 12194, Research Triangle Park, NC, 27709-2194, USA.
| | - Amie C O'Donoghue
- Office of Prescription Drug Promotion, Office of Medical Policy, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, US
| | - Kevin R Betts
- Office of Prescription Drug Promotion, Office of Medical Policy, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, US
| | - Ryan S Paquin
- RTI International, 3040 E. Cornwallis Road, PO Box 12194, Research Triangle Park, NC, 27709-2194, USA
| | - Kristen Giombi
- RTI International, 3040 E. Cornwallis Road, PO Box 12194, Research Triangle Park, NC, 27709-2194, USA
| | - Jennifer E Arnold
- Department of Psychology and Neuroscience, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Bridget J Kelly
- RTI International, 3040 E. Cornwallis Road, PO Box 12194, Research Triangle Park, NC, 27709-2194, USA
| | - Christine Davis
- RTI International, 3040 E. Cornwallis Road, PO Box 12194, Research Triangle Park, NC, 27709-2194, USA
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Woldeamanuel YW, Sanjanwala BM, Cowan RP. Deep and unbiased proteomics, pathway enrichment analysis, and protein-protein interaction of biomarker signatures in migraine. Ther Adv Chronic Dis 2024; 15:20406223241274302. [PMID: 39314676 PMCID: PMC11418313 DOI: 10.1177/20406223241274302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 07/24/2024] [Indexed: 09/25/2024] Open
Abstract
Background Currently, there are no biomarkers for migraine. Objectives We aimed to identify proteomic biomarker signatures for diagnosing, subclassifying, and predicting treatment response in migraine. Design This is a cross-sectional and longitudinal study of untargeted serum and cerebrospinal fluid (CSF) proteomics in episodic migraine (EM; n = 26), chronic migraine (CM; n = 26), and healthy controls (HC; n = 26). Methods We developed classification models for biomarker identification and natural clusters through unsupervised classification using agglomerative hierarchical clustering (AHC). Pathway analysis of differentially expressed proteins was performed. Results Of 405 CSF proteins, the top five proteins that discriminated between migraine patients and HC were angiotensinogen, cell adhesion molecule 3, immunoglobulin heavy variable (IGHV) V-III region JON, insulin-like growth factor binding protein 6 (IGFBP-6), and IGFBP-7. The top-performing classifier demonstrated 100% sensitivity and 75% specificity in differentiating the two groups. Of 229 serum proteins, the top five proteins in classifying patients with migraine were immunoglobulin heavy variable 3-74 (IGHV 3-74), proteoglycan 4, immunoglobulin kappa variable 3D-15, zinc finger protein (ZFP)-814, and mediator of RNA polymerase II transcription subunit 12. The best-performing classifier exhibited 94% sensitivity and 92% specificity. AHC separated EM, CM, and HC into distinct clusters with 90% success. Migraine patients exhibited increased ZFP-814 and calcium voltage-gated channel subunit alpha 1F (CACNA1F) levels, while IGHV 3-74 levels decreased in both cross-sectional and longitudinal serum analyses. ZFP-814 remained upregulated during the CM-to-EM reversion but was suppressed when CM persisted. CACNA1F was pronounced in CM persistence. Pathway analysis revealed immune, coagulation, glucose metabolism, erythrocyte oxygen and carbon dioxide exchange, and insulin-like growth factor regulation pathways. Conclusion Our data-driven study provides evidence for identifying novel proteomic biomarker signatures to diagnose, subclassify, and predict treatment responses for migraine. The dysregulated biomolecules affect multiple pathways, leading to cortical spreading depression, trigeminal nociceptor sensitization, oxidative stress, blood-brain barrier disruption, immune response, and coagulation cascades. Trial registration NCT03231241, ClincialTrials.gov.
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Affiliation(s)
- Yohannes W. Woldeamanuel
- Division of Headache, Department of Neurology, Mayo Clinic Arizona, 6161 E. Mayo Blvd, Phoenix, AZ, USA
| | - Bharati M. Sanjanwala
- Division of Headache and Facial Pain, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA, USA
| | - Robert P. Cowan
- Division of Headache and Facial Pain, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA, USA
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Dharanikota H, Wigmore SJ, Skipworth R, Yule S. Mapping cognitive biases in multidisciplinary team (MDT) decision-making for cancer care in Scotland: a cognitive ethnography study protocol. BMJ Open 2024; 14:e086775. [PMID: 39181560 PMCID: PMC11404157 DOI: 10.1136/bmjopen-2024-086775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/27/2024] Open
Abstract
INTRODUCTION The efficiency of multidisciplinary teams (MDTs) in cancer care hinges on facilitating clinicians' cognitive processes as they navigate complex and uncertain judgements during treatment planning. When systems and workflows are not designed to adequately support human judgement and decision-making, even experts are prone to fallible reasoning due to cognitive biases. Incomplete integration of information or biased interpretations of patient data can lead to clinical errors and delays in the implementation of treatment recommendations. Though their impact is intuitively recognised, there is currently a paucity of empirical work on cognitive biases in MDT decision-making. Our study aims to explicate the impact of such biases on treatment planning and establish a foundation for targeted investigations and interventions to mitigate their negative effects. METHODS AND ANALYSIS This is a qualitative, observational study. We employ cognitive ethnography, informed by the Distributed Cognition for Teamwork framework to assess and evaluate MDT decision-making processes. The study involves in-person and virtual field observations of hepatopancreaticobiliary and upper gastrointestinal MDTs and interviews with their members over several months. The data generated will be analysed in a hybrid inductive/deductive fashion to develop a comprehensive map of potential cognitive biases in MDT decision processes identifying antecedents and risk factors of suboptimal treatment planning processes. Further, we will identify components of the MDT environment that can be redesigned to support decision-making via development of an MDT workspace evaluation tool. ETHICS AND DISSEMINATION This project has received management and ethical approvals from NHS Lothian Research and Development (2023/0245) and the University of Edinburgh Medical School ethical review committee (23-EMREC-049). Findings will be shared with participating MDTs and disseminated via a PhD thesis, international conference presentations and relevant scientific journals.
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Affiliation(s)
- Harini Dharanikota
- Surgical Sabermetrics Laboratory, Centre for Medical Informatics, Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Stephen J Wigmore
- Surgical Sabermetrics Laboratory, Centre for Medical Informatics, Usher Institute, The University of Edinburgh, Edinburgh, UK
- Clinical Surgery, University of Edinburgh & Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Richard Skipworth
- Surgical Sabermetrics Laboratory, Centre for Medical Informatics, Usher Institute, The University of Edinburgh, Edinburgh, UK
- Clinical Surgery, University of Edinburgh & Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Steven Yule
- Surgical Sabermetrics Laboratory, Centre for Medical Informatics, Usher Institute, The University of Edinburgh, Edinburgh, UK
- Clinical Surgery, University of Edinburgh & Royal Infirmary of Edinburgh, Edinburgh, UK
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11
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Norman G, Pelaccia T, Wyer P, Sherbino J. Dual process models of clinical reasoning: The central role of knowledge in diagnostic expertise. J Eval Clin Pract 2024; 30:788-796. [PMID: 38825755 DOI: 10.1111/jep.13998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 01/17/2024] [Accepted: 04/09/2024] [Indexed: 06/04/2024]
Abstract
RATIONALE Research on diagnostic reasoning has been conducted for fifty years or more. There is growing consensus that there are two distinct processes involved in human diagnostic reasoning: System 1, a rapid retrieval of possible diagnostic hypotheses, largely automatic and based to a large part on experiential knowledge, and System 2, a slower, analytical, conscious application of formal knowledge to arrive at a diagnostic conclusion. However, within this broad framework, controversy and disagreement abound. In particular, many authors have suggested that the root cause of diagnostic errors is cognitive biases originating in System 1 and propose that educating learners about the types of cognitive biases and their impact on diagnosis would have a major influence on error reduction. AIMS AND OBJECTIVES In the present paper, we take issue with these claims. METHOD We reviewed the literature to examine the extent to which this theoretical model is supported by the evidence. RESULTS We show that evidence derived from fundamental research in human cognition and studies in clinical medicine challenges the basic assumptions of this theory-that errors arise in System 1 processing as a consequence of cognitive biases, and are corrected by slow, deliberative analytical processing. We claim that, to the contrary, errors derive from both System 1 and System 2 reasoning, that they arise from lack of access to the appropriate knowledge, not from errors of processing, and that the two processes are not essential to the process of diagnostic reasoning. CONCLUSIONS The two processing modes are better understood as a consequence of the nature of the knowledge retrieved, not as independent processes.
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Affiliation(s)
- Geoff Norman
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Thierry Pelaccia
- Centre for Training and Research in Health Sciences Education (CFRPS), Faculty of Medicine, University of Strasbourg, Strasbourg, France
| | - Peter Wyer
- Department of Emergency Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Jonathan Sherbino
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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12
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Luz PM, Apelian H, Lambert G, Fourmigue A, Dvorakova M, Grace D, Lachowsky N, Hart TA, Moore DM, Skakoon-Sparling S, Cox J. HIV Treatment Optimism Moderates the Relationship between Sexual Risk Behavior and HIV Risk Perception among Urban HIV-negative Gay, Bisexual, and Other Men who have Sex With Men. AIDS Behav 2024; 28:2683-2694. [PMID: 38869761 DOI: 10.1007/s10461-024-04380-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/15/2024] [Indexed: 06/14/2024]
Abstract
Using baseline data of the Engage Cohort Study, a Canadian study of sexually active gay, bisexual and other men who have sex with men (GBM), we evaluated the association between sexual behavior and risk perception among HIV-negative participants and whether HIV treatment optimism moderated this relationship. Participants were recruited by respondent-driven-sampling (RDS). We defined high-risk sexual behavior in the past six months as any condomless anal sex with a casual partner (i.e. not the participant's main partner) with either unknown HIV-status where neither used pre-exposure prophylaxis or with a partner living with HIV having detectable/unknown viral load. We assessed HIV treatment optimism-skepticism using a 12-item scale. RDS-II-weighted adjusted logistic regression models examined associations with risk perception measured by the question "How would you assess your current risk of getting HIV?" (response options were on a 6-point Likert-scale ranging from "very unlikely" to "very likely", dichotomized into "No Perceived Risk" (very unlikely/unlikely) and "Perceived Risk" (somewhat likely/likely/very likely/I think I already have HIV). Of 1961 participants, engagement in high-risk sexual behavior was reported by 155 (17.0%), 62 (12.4%), 128 (17.2%) of participants in Montréal, Toronto, and Vancouver, respectively. High-risk sexual behavior increased the odds of perceived HIV risk (pooled adjusted odds ratio = 2.9, 95%CI = 2.2-3.8). HIV treatment optimism-skepticism scores moderated the relationship: for GBM engaging in high-risk sexual behavior, higher HIV treatment optimism-skepticism scores increased perceived HIV risk. Promoting awareness around advances related to HIV prevention and treatment is important for appropriate risk assessment and for increased engagement in prevention interventions.
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Affiliation(s)
- Paula M Luz
- National Institute of Infectious Disease Evandro Chagas, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil.
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Av. Brasil 4365, Manguinhos, Rio de Janeiro, 21040-900, Brazil.
| | - Herak Apelian
- Research Institute of the McGill University Health Centre, Montréal, QC, Canada
| | - Gilles Lambert
- Direction régionale de santé publique de Montréal, CIUSSS Centre-Sud-de-l'Ile-de-Montréal, Montréal, QC, Canada
- Institut national de santé publique du Québec, Montréal, QC, Canada
| | - Alain Fourmigue
- Research Institute of the McGill University Health Centre, Montréal, QC, Canada
| | - Milada Dvorakova
- Research Institute of the McGill University Health Centre, Montréal, QC, Canada
| | - Daniel Grace
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Nathan Lachowsky
- School of Public, Health & Social Policy, University of Victoria, Victoria, BC, Canada
| | - Trevor A Hart
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Department of Psychology, Toronto Metropolitan University, Toronto, ON, Canada
| | - David M Moore
- BC Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - Shayna Skakoon-Sparling
- Department of Psychology, Toronto Metropolitan University, Toronto, ON, Canada
- Psychology Department, University of Guelph, Guelph, ON, Canada
| | - Joseph Cox
- Research Institute of the McGill University Health Centre, Montréal, QC, Canada
- Direction régionale de santé publique de Montréal, CIUSSS Centre-Sud-de-l'Ile-de-Montréal, Montréal, QC, Canada
- Department of Epidemiology, Biostatistics & Occupational Health, McGill University, Montréal, QC, Canada
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Sayegh F. Leveraging emotional intelligence to foster proactive climate change adaptation: A study of engineering decision-making. JOURNAL OF ENVIRONMENTAL MANAGEMENT 2024; 365:121669. [PMID: 38968887 DOI: 10.1016/j.jenvman.2024.121669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 06/25/2024] [Accepted: 06/30/2024] [Indexed: 07/07/2024]
Abstract
The impacts of climate change and development present significant challenges and complexities that require new solutions, wise choices, and multi-disciplinary integration. In this context, emotional intelligence (EI) plays a crucial role. However, traditional engineering education and practice overlook the importance of understanding and managing emotions. This research aims to determine the impact of EI as a tool to enhance proactive decision-making and implement sustainable measures within the engineering profession.The study makes three main research contributions. First, it confirms a positive relationship between EI and proactive sustainable decision-making among engineers. This means that engineers with high EI are more likely to consider the impacts of their decisions on various stakeholders and dimensions of sustainability. Second, it suggests that EI can enhance creativity and innovative thinking in engineering, helping engineers to develop effective solutions for challenges related to climate change. Third, the study advocates for incorporating EI training and assessment into engineering curriculums to foster a sustainable and ethical engineering culture. By improving EI, engineers can enhance their interpersonal skills, self-awareness, and emotional management, which in turn can significantly improve teamwork in addressing challenges related to climate change.
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Affiliation(s)
- Fadi Sayegh
- UCAM (Universidad Católica San Antonio de Murcia), Spain.
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14
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Yung KK, Ardern CL, Serpiello FR, Robertson S. Judgement and Decision Making in Clinical and Return-to-Sports Decision Making: A Narrative Review. Sports Med 2024; 54:2005-2017. [PMID: 38922556 PMCID: PMC11329672 DOI: 10.1007/s40279-024-02054-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/22/2024] [Indexed: 06/27/2024]
Abstract
Making return-to-sport decisions can be complex and multi-faceted, as it requires an evaluation of an individual's physical, psychological, and social well-being. Specifically, the timing of progression, regression, or return to sport can be difficult to determine due to the multitude of information that needs to be considered by clinicians. With the advent of new sports technology, the increasing volume of data poses a challenge to clinicians in effectively processing and utilising it to enhance the quality of their decisions. To gain a deeper understanding of the mechanisms underlying human decision making and associated biases, this narrative review provides a brief overview of different decision-making models that are relevant to sports rehabilitation settings. Accordingly, decisions can be made intuitively, analytically, and/or with heuristics. This narrative review demonstrates how the decision-making models can be applied in the context of return-to-sport decisions and shed light on strategies that may help clinicians improve decision quality.
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Affiliation(s)
- Kate K Yung
- Institute for Health and Sport, Victoria University, Melbourne, Australia.
- Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong, China.
| | - Clare L Ardern
- Sport and Exercise Medicine Research Centre, La Trobe University, Melbourne, Australia
- Department of Physical Therapy, University of British Columbia, Vancouver, Canada
| | - Fabio R Serpiello
- Institute for Health and Sport, Victoria University, Melbourne, Australia
- Human Exercise and Training Lab, School of Health Medical and Applied Sciences, Central Queensland University, Rockhampton, Australia
| | - Sam Robertson
- Institute for Health and Sport, Victoria University, Melbourne, Australia
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Plaum P, Visser LN, de Groot B, Morsink ME, Duijst WL, Candel BG. Using case vignettes to study the presence of outcome, hindsight, and implicit bias in acute unplanned medical care: a cross-sectional study. Eur J Emerg Med 2024; 31:260-266. [PMID: 38364049 PMCID: PMC11198948 DOI: 10.1097/mej.0000000000001127] [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] [Received: 10/23/2023] [Accepted: 01/16/2024] [Indexed: 02/18/2024]
Abstract
BACKGROUND AND IMPORTANCE Various biases can impact decision-making and judgment of case quality in the Emergency Department (ED). Outcome and hindsight bias can lead to wrong retrospective judgment of care quality, and implicit bias can result in unjust treatment differences in the ED based on irrelevant patient characteristics. OBJECTIVES First, to evaluate the extent to which knowledge of an outcome influences physicians' quality of care assessment. Secondly, to examine whether patients with functional disorders receive different treatment compared to patients with a somatic past medical history. DESIGN A web-based cross-sectional study in which physicians received case vignettes with a case description and care provided. Physicians were informed about vignette outcomes in a randomized way (no, good, or bad outcome). Physicians rated quality of care for four case vignettes with different outcomes. Subsequently, they received two more case vignettes. Physicians were informed about the past medical history of the patient in a randomized way (somatic or functional). Physicians made treatment and diagnostic decisions for both cases. SETTING AND PARTICIPANTS One hundred ninety-one Dutch emergency physicians (EPs) and general practitioners (GPs) participated. OUTCOME MEASURES AND ANALYSIS Quality of care was rated on a Likert scale (0-5) and dichotomized as adequate (yes/no). Physicians estimated the likelihood of patients experiencing a bad outcome for hindsight bias. For the second objective, physicians decided on prescribing analgesics and additional diagnostic tests. MAIN RESULTS Large differences existed in rated quality of care for three out of four vignettes based on different case outcomes. For example, physicians rated the quality of care as adequate in 44% (95% CI 33-57%) for an abdominal pain case with a bad outcome, compared to 88% (95% CI 78-94%) for a good outcome, and 84% (95% CI 73-91%) for no outcome ( P < 0.01). The estimated likelihood of a bad outcome was higher if physicians received a vignette with a bad patient outcome. Fewer diagnostic tests were performed and fewer opioids were prescribed for patients with a functional disorder. CONCLUSION Outcome, hindsight, and implicit bias significantly influence decision-making and care quality assessment by Dutch EPs and GPs.
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Affiliation(s)
- Patricia Plaum
- Emergency Department, Zuyderland Medical Centre, Heerlen
| | | | - Bas de Groot
- Emergency Department, Radboud University Medical Centre, Nijmegen
| | | | - Wilma L.J.M. Duijst
- Faculty of Law and Criminology, Maastricht University, Maastricht
- GGD IJsselland, Zwolle
| | - Bart G.J. Candel
- Emergency Department, Leiden University Medical Centre, Leiden, The Netherlands
- Emergency Department, Fiona Stanley Hospital, Perth, Australia
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16
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Tan HJ, Spratte BN, Deal AM, Heiling HM, Nazzal EM, Meeks W, Fang R, Teal R, Vu MB, Bennett AV, Blalock SJ, Chung AE, Gotz D, Nielsen ME, Reuland DS, Harris AH, Basch E. Clinical Decision Support for Surgery: A Mixed Methods Study on Design and Implementation Perspectives From Urologists. Urology 2024; 190:15-23. [PMID: 38697362 PMCID: PMC11344670 DOI: 10.1016/j.urology.2024.04.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 04/08/2024] [Accepted: 04/20/2024] [Indexed: 05/05/2024]
Abstract
OBJECTIVE To assess urologist attitudes toward clinical decision support (CDS) embedded into the electronic health record (EHR) and define design needs to facilitate implementation and impact. With recent advances in big data and artificial intelligence (AI), enthusiasm for personalized, data-driven tools to improve surgical decision-making has grown, but the impact of current tools remains limited. METHODS A sequential explanatory mixed methods study from 2019 to 2020 was performed. First, survey responses from the 2019 American Urological Association Annual Census evaluated attitudes toward an automatic CDS tool that would display risk/benefit data. This was followed by the purposeful sampling of 25 urologists and qualitative interviews assessing perspectives on CDS impact and design needs. Bivariable, multivariable, and coding-based thematic analysis were applied and integrated. RESULTS Among a weighted sample of 12,366 practicing urologists, the majority agreed CDS would help decision-making (70.9%, 95% CI 68.7%-73.2%), aid patient counseling (78.5%, 95% CI 76.5%-80.5%), save time (58.1%, 95% CI 55.7%-60.5%), and improve patient outcomes (42.9%, 95% CI 40.5%-45.4%). More years in practice was negatively associated with agreement (P <.001). Urologists described how CDS could bolster evidence-based care, personalized medicine, resource utilization, and patient experience. They also identified multiple implementation barriers and provided suggestions on form, functionality, and visual design to improve usefulness and ease of use. CONCLUSION Urologists have favorable attitudes toward the potential for clinical decision support in the EHR. Smart design will be critical to ensure effective implementation and impact.
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Affiliation(s)
- Hung-Jui Tan
- Department of Urology, School of Medicine, University of North Carolina, Chapel Hill, NC; Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina, Chapel Hill, NC.
| | - Brooke N Spratte
- Department of Urology, School of Medicine, University of North Carolina, Chapel Hill, NC
| | - Allison M Deal
- Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina, Chapel Hill, NC
| | - Hillary M Heiling
- Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina, Chapel Hill, NC
| | - Elizabeth M Nazzal
- Department of Urology, School of Medicine, University of North Carolina, Chapel Hill, NC
| | - William Meeks
- American Urological Association Data Management and Statistical Services
| | - Raymond Fang
- American Urological Association Data Management and Statistical Services
| | - Randall Teal
- Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina, Chapel Hill, NC; Connected Health Applications and Interventions Core, University of North Carolina, Chapel Hill, NC
| | - Maihan B Vu
- Connected Health Applications and Interventions Core, University of North Carolina, Chapel Hill, NC; Center for Health Promotion and Disease Prevention, University of North Carolina, Chapel Hill, NC
| | - Antonia V Bennett
- Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina, Chapel Hill, NC; Department of Health Policy & Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
| | - Susan J Blalock
- Pharmaceutical Outcomes & Policy, Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC
| | - Arlene E Chung
- Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina, Chapel Hill, NC; Department of Bioinformatics, Duke University, Durham, NC
| | - David Gotz
- Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina, Chapel Hill, NC; School of Information and Library Science, University of North Carolina, Chapel Hill, NC
| | - Matthew E Nielsen
- Department of Urology, School of Medicine, University of North Carolina, Chapel Hill, NC; Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina, Chapel Hill, NC; Department of Health Policy & Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
| | - Daniel S Reuland
- Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina, Chapel Hill, NC; Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC
| | - Alex Hs Harris
- Department of Surgery, School of Medicine, Stanford University, Palo Alto, CA
| | - Ethan Basch
- Lineberger Comprehensive Cancer Center, School of Medicine, University of North Carolina, Chapel Hill, NC; Department of Health Policy & Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC; Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC
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17
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Yan L, Karamchandani K, Gaiser RR, Carr ZJ. Identifying, Understanding, and Minimizing Unconscious Cognitive Biases in Perioperative Crisis Management: A Narrative Review. Anesth Analg 2024; 139:68-77. [PMID: 37874227 DOI: 10.1213/ane.0000000000006666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
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.
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Affiliation(s)
- Luying Yan
- From the Yale University School of Medicine, New Haven, Connecticut
| | - Kunal Karamchandani
- Department of Anesthesiology
- University of Texas, Southwestern Medical School, Dallas, Texas
| | - Robert R Gaiser
- From the Yale University School of Medicine, New Haven, Connecticut
- Department of Anesthesiology
| | - Zyad J Carr
- From the Yale University School of Medicine, New Haven, Connecticut
- Department of Anesthesiology
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18
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Butler JM, Taft T, Taber P, Rutter E, Fix M, Baker A, Weir C, Nevers M, Classen D, Cosby K, Jones M, Chapman A, Jones BE. Pneumonia diagnosis performance in the emergency department: a mixed-methods study about clinicians' experiences and exploration of individual differences and response to diagnostic performance feedback. J Am Med Inform Assoc 2024; 31:1503-1513. [PMID: 38796835 PMCID: PMC11187426 DOI: 10.1093/jamia/ocae112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 03/25/2024] [Accepted: 05/22/2024] [Indexed: 05/29/2024] Open
Abstract
OBJECTIVES We sought to (1) characterize the process of diagnosing pneumonia in an emergency department (ED) and (2) examine clinician reactions to a clinician-facing diagnostic discordance feedback tool. MATERIALS AND METHODS We designed a diagnostic feedback tool, using electronic health record data from ED clinicians' patients to establish concordance or discordance between ED diagnosis, radiology reports, and hospital discharge diagnosis for pneumonia. We conducted semistructured interviews with 11 ED clinicians about pneumonia diagnosis and reactions to the feedback tool. We administered surveys measuring individual differences in mindset beliefs, comfort with feedback, and feedback tool usability. We qualitatively analyzed interview transcripts and descriptively analyzed survey data. RESULTS Thematic results revealed: (1) the diagnostic process for pneumonia in the ED is characterized by diagnostic uncertainty and may be secondary to goals to treat and dispose the patient; (2) clinician diagnostic self-evaluation is a fragmented, inconsistent process of case review and follow-up that a feedback tool could fill; (3) the feedback tool was described favorably, with task and normative feedback harnessing clinician values of high-quality patient care and personal excellence; and (4) strong reactions to diagnostic feedback varied from implicit trust to profound skepticism about the validity of the concordance metric. Survey results suggested a relationship between clinicians' individual differences in learning and failure beliefs, feedback experience, and usability ratings. DISCUSSION AND CONCLUSION Clinicians value feedback on pneumonia diagnoses. Our results highlight the importance of feedback about diagnostic performance and suggest directions for considering individual differences in feedback tool design and implementation.
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Affiliation(s)
- Jorie M Butler
- Department of Biomedical Informatics, University of Utah Spencer Fox Eccles School of Medicine, Salt Lake City, UT 84108, United States
- Department of Internal Medicine, Division of Geriatrics, University of Utah Spencer Fox Eccles School of Medicine, Salt Lake City, UT 84132, United States
- Salt Lake City VA Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center for Innovation, Salt Lake City, UT 84148, United States
- Geriatrics Research, Education, and Clinical Center (GRECC), VA Salt Lake City Health Care System, Salt Lake City, UT 84148, United States
| | - Teresa Taft
- Department of Biomedical Informatics, University of Utah Spencer Fox Eccles School of Medicine, Salt Lake City, UT 84108, United States
| | - Peter Taber
- Department of Biomedical Informatics, University of Utah Spencer Fox Eccles School of Medicine, Salt Lake City, UT 84108, United States
- Salt Lake City VA Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center for Innovation, Salt Lake City, UT 84148, United States
| | - Elizabeth Rutter
- Department of Emergency Medicine, University of Utah Spencer Fox Eccles School of Medicine, Salt Lake City, UT 84108, United States
| | - Megan Fix
- Department of Emergency Medicine, University of Utah Spencer Fox Eccles School of Medicine, Salt Lake City, UT 84108, United States
| | - Alden Baker
- Department of Family and Preventive Medicine, Division of Physician Assistant Studies, University of Utah Spencer Fox Eccles School of Medicine, Salt Lake City, UT 84108, United States
| | - Charlene Weir
- Department of Biomedical Informatics, University of Utah Spencer Fox Eccles School of Medicine, Salt Lake City, UT 84108, United States
| | - McKenna Nevers
- Department of Internal Medicine, Division of Epidemiology, University of Utah Spencer Fox Eccles School of Medicine, Salt Lake City, UT 84108, United States
| | - David Classen
- Department of Internal Medicine, Division of Epidemiology, University of Utah Spencer Fox Eccles School of Medicine, Salt Lake City, UT 84108, United States
| | - Karen Cosby
- Department of Emergency Medicine, Cook County Hospital, Rush Medical College, Chicago, IL 60612, United States
| | - Makoto Jones
- Salt Lake City VA Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center for Innovation, Salt Lake City, UT 84148, United States
- Department of Internal Medicine, Division of Epidemiology, University of Utah Spencer Fox Eccles School of Medicine, Salt Lake City, UT 84108, United States
| | - Alec Chapman
- Department of Population Health Sciences, University of Utah Spencer Fox Eccles School of Medicine, Salt Lake City, UT 84108, United States
| | - Barbara E Jones
- Salt Lake City VA Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center for Innovation, Salt Lake City, UT 84148, United States
- Department of Internal Medicine, Division of Pulmonology, University of Utah Spencer Fox Eccles School of Medicine, Salt Lake City, UT 84108, United States
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Edelstein AI, Tanenbaum JT, McGinley EL, Dillingham TR, Pezzin LE. Age-Based Heuristics Bias Treatment of Displaced Femoral Neck Fractures in the Elderly. Arthroplast Today 2024; 27:101356. [PMID: 38524153 PMCID: PMC10958215 DOI: 10.1016/j.artd.2024.101356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 02/07/2024] [Accepted: 02/13/2024] [Indexed: 03/26/2024] Open
Abstract
Background Surgeons performing arthroplasty for femoral neck fractures may rely on mental shortcuts (heuristics) when choosing total hip arthroplasty (THA) vs hemiarthroplasty (HA). We sought to quantify the extent to which age-based heuristics drive decision-making. Methods We identified all Medicare beneficiaries from 2017-2018 with femoral neck fractures who underwent THA or HA. We compared the likelihood of THA vs HA among patients admitted within 4 weeks before vs 4 weeks after their birthday for each age under the hypothesis that these cohorts would be similar except for numerical age. We controlled for race/ethnicity, sex, comorbidities, poverty status, and hospital census region in a multivariable regression that included facility-level cluster effects. We generated predicted/adjusted probabilities for THA vs HA for different age transition points. Results Thirteen thousand three hundred sixty-six elderly patients were included. One thousand eight hundred sixty-five (14%) received THA and 11,501 (86%) received HA. The likelihood of THA decreased from 50.3% among patients almost 67 to 8% among those ≥85 (P < .001). We found significant decreases in likelihood of THA across age transitions. The largest decrement was at age transition 69 (THA likelihood 28.7% for newly 69 vs 43.3% for almost 69, 33.7% relative change). Female gender, Black race, higher comorbidity burden, and lower socioeconomic status were also associated with a lower likelihood of THA. Conclusions Our data demonstrate that patient age transitions seem to influence the choice of THA vs HA. Further research is needed to develop data-driven surgical decision aids for this population.
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Affiliation(s)
- Adam I. Edelstein
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Joseph T. Tanenbaum
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Emily L. McGinley
- Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Timothy R. Dillingham
- Department of Physical Medicine and Rehabilitation, The University of Pennsylvania, Philadelphia, PA, USA
| | - Liliana E. Pezzin
- Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI, USA
- Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI, USA
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Loftus TJ, Ruppert MM, Shickel B, Ozrazgat-Baslanti T, Balch JA, Abbott KL, Hu D, Javed A, Madbak F, Guirgis F, Skarupa D, Efron PA, Tighe PJ, Hogan WR, Rashidi P, Upchurch GR, Bihorac A. Association of Sociodemographic Factors With Overtriage, Undertriage, and Value of Care After Major Surgery. ANNALS OF SURGERY OPEN 2024; 5:e429. [PMID: 38911666 PMCID: PMC11191932 DOI: 10.1097/as9.0000000000000429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 04/09/2024] [Indexed: 06/25/2024] Open
Abstract
Objective To determine whether certain patients are vulnerable to errant triage decisions immediately after major surgery and whether there are unique sociodemographic phenotypes within overtriaged and undertriaged cohorts. Background In a fair system, overtriage of low-acuity patients to intensive care units (ICUs) and undertriage of high-acuity patients to general wards would affect all sociodemographic subgroups equally. Methods This multicenter, longitudinal cohort study of hospital admissions immediately after major surgery compared hospital mortality and value of care (risk-adjusted mortality/total costs) across 4 cohorts: overtriage (N = 660), risk-matched overtriage controls admitted to general wards (N = 3077), undertriage (N = 2335), and risk-matched undertriage controls admitted to ICUs (N = 4774). K-means clustering identified sociodemographic phenotypes within overtriage and undertriage cohorts. Results Compared with controls, overtriaged admissions had a predominance of male patients (56.2% vs 43.1%, P < 0.001) and commercial insurance (6.4% vs 2.5%, P < 0.001); undertriaged admissions had a predominance of Black patients (28.4% vs 24.4%, P < 0.001) and greater socioeconomic deprivation. Overtriage was associated with increased total direct costs [$16.2K ($11.4K-$23.5K) vs $14.1K ($9.1K-$20.7K), P < 0.001] and low value of care; undertriage was associated with increased hospital mortality (1.5% vs 0.7%, P = 0.002) and hospice care (2.2% vs 0.6%, P < 0.001) and low value of care. Unique sociodemographic phenotypes within both overtriage and undertriage cohorts had similar outcomes and value of care, suggesting that triage decisions, rather than patient characteristics, drive outcomes and value of care. Conclusions Postoperative triage decisions should ensure equality across sociodemographic groups by anchoring triage decisions to objective patient acuity assessments, circumventing cognitive shortcuts and mitigating bias.
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Affiliation(s)
- Tyler J. Loftus
- From the Intelligent Critical Care Center, University of Florida, Gainesville, FL
- Department of Surgery, University of Florida Health, Gainesville, FL
| | - Matthew M. Ruppert
- From the Intelligent Critical Care Center, University of Florida, Gainesville, FL
- Department of Medicine, University of Florida Health, Gainesville, FL
| | - Benjamin Shickel
- From the Intelligent Critical Care Center, University of Florida, Gainesville, FL
- Department of Medicine, University of Florida Health, Gainesville, FL
| | - Tezcan Ozrazgat-Baslanti
- From the Intelligent Critical Care Center, University of Florida, Gainesville, FL
- Department of Medicine, University of Florida Health, Gainesville, FL
| | - Jeremy A. Balch
- From the Intelligent Critical Care Center, University of Florida, Gainesville, FL
- Department of Surgery, University of Florida Health, Gainesville, FL
- Departments of Biomedical Engineering, Computer and Information Science and Engineering, and Electrical and Computer Engineering, University of Florida, Gainesville, FL
| | - Kenneth L. Abbott
- Department of Surgery, University of Florida Health, Gainesville, FL
| | - Die Hu
- From the Intelligent Critical Care Center, University of Florida, Gainesville, FL
- Department of Surgery, University of Florida Health, Gainesville, FL
| | - Adnan Javed
- Departments of Emergency Medicine & Critical Care Medicine, University of Florida College of Medicine, Jacksonville, FL
| | - Firas Madbak
- Department of Surgery, University of Florida College of Medicine, Jacksonville, FL
| | - Faheem Guirgis
- Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville, FL
| | - David Skarupa
- Department of Surgery, University of Florida College of Medicine, Jacksonville, FL
| | - Philip A. Efron
- Department of Surgery, University of Florida Health, Gainesville, FL
| | - Patrick J. Tighe
- Departments of Anesthesiology, Orthopedics, and Information Systems/Operations Management, University of Florida Health, Gainesville, FL
| | - William R. Hogan
- Department of Health Outcomes & Biomedical Informatics, College of Medicine, University of Florida, Gainesville, FL
| | - Parisa Rashidi
- From the Intelligent Critical Care Center, University of Florida, Gainesville, FL
- Departments of Biomedical Engineering, Computer and Information Science and Engineering, and Electrical and Computer Engineering, University of Florida, Gainesville, FL
| | | | - Azra Bihorac
- From the Intelligent Critical Care Center, University of Florida, Gainesville, FL
- Department of Surgery, University of Florida Health, Gainesville, FL
- Department of Medicine, University of Florida Health, Gainesville, FL
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McGurgan P, Calvert K, Celenza A, Nathan EA, Jorm C. The Schweitzer effect: The fundamental relationship between experience and medical students' opinions on professional behaviours. MEDICAL TEACHER 2024; 46:782-791. [PMID: 38048408 DOI: 10.1080/0142159x.2023.2284660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/06/2023]
Abstract
PURPOSE We examined whether medical students' opinions on the acceptability of a behaviour were influenced by previously encountering a similar professionally challenging situation, assessed the magnitude of effect of 'experience' compared to other demographic factors which influence medical students' opinions, and evaluated whether opinions regarding some situations/behaviours were more susceptible to 'experience' bias? METHODS Confidential, on-line survey for medical students distributed to Australian and New Zealand (AUS/NZ) medical schools. Students submitted de-identified demographic information, provided opinions on the acceptability of a wide range of student behaviours in professionally challenging situations, and whether they had encountered similar situations. RESULTS 3171 students participated from all 21 Aus/NZ medical schools (16% of registered students). Medical students reported encountering many of the professionally challenging situations, with varying opinions on what was acceptable behaviour. The most significant factor influencing acceptability towards a behaviour was whether the student reported encountering a similar situation. The professional dilemmas most significantly influenced by previous experience typically related to behaviours that students could witness in clinical environments, and often involved breaches of trust. CONCLUSIONS Our results demonstrate the relationship between experience and medical students' opinions on professional behaviour- the 'Schweitzer effect'. When students encounter poor examples of professional behaviour, especially concerning trust breaches, it significantly influences their perception of the behaviour. These results highlight the importance of placing students in healthcare settings with positive professional role modelling/work cultures.
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Affiliation(s)
- Paul McGurgan
- Division of Obstetrics and Gynaecology, UWA Medical School, Perth, Australia
| | - Katrina Calvert
- Dept. of Post-Graduate Medical Education (PGME), K.E.M.H., Perth, Australia
| | - Antonio Celenza
- Division of Emergency Medicine, UWA Medical School, Perth, Australia
| | - Elizabeth A Nathan
- Division of Obstetrics and Gynaecology, UWA Medical School, Perth, Australia
| | - Christine Jorm
- School of Public Health, University of Sydney, Australia
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22
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Iversen AM, Hansen MB, Münster M, Kristensen B, Ellermann-Eriksen S. Hand hygiene compliance in nursing home wards: the effect of increased accessibility of alcohol-based hand rub. J Hosp Infect 2024; 147:206-212. [PMID: 38521416 DOI: 10.1016/j.jhin.2024.02.027] [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] [Received: 12/21/2023] [Revised: 02/26/2024] [Accepted: 02/28/2024] [Indexed: 03/25/2024]
Abstract
BACKGROUND Elderly nursing home residents are vulnerable to infection from micro-organisms. Hand hygiene is considered one of the most important measures to prevent transmission. AIM To determine the effect of increased accessibility to alcohol-based hand rub (ABHR) in nursing home wards by monitoring hand hygiene compliance (HHC) among healthcare workers (HCWs). METHODS An 11-month intervention study was conducted in a Danish six-ward nursing home. Data were collected using an automatic hand hygiene monitoring system (AHHMS). After a baseline period, one extra ABHR dispenser was placed in each of the 150 apartments. Baseline HHC was compared with the HHC during an immediate intervention period and a long-term intervention period. FINDINGS A total of 159 HCWs were included. The AHHMS registered 341,078 hand hygiene opportunities. Overall baseline HHC was 31% (95% confidence interval: 30-32). A significant +18% absolute immediate effect (first five months) (95% CI: 17-19; P < 0.0001) and +13 percentage points (95% CI: 11-14; P < 0.0001) long-term effect (another four months) were recorded. HCWs working day shifts and short-term employees had a higher baseline HHC than HCWs working evening/night shifts. However, HCWs working night shifts achieved the greatest long-term effect with a mean +27 percentage point difference (P < 0.0001). CONCLUSION Placing an additional ABHR dispenser strategically within staff workflow significantly increased HHC among HCWs, demonstrating a noteworthy effect. The study is the first to report the effect on nursing home dispenser accessibility as a single intervention and to show a significant unmet potential.
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Affiliation(s)
- A-M Iversen
- Department of Oncology, Aarhus University Hospital and Aarhus University, Denmark.
| | - M B Hansen
- Konduto ApS, Sani Nudge, Copenhagen, Denmark
| | | | - B Kristensen
- National Centre of Infection Control, Statens Serum Institut, Copenhagen, Denmark
| | - S Ellermann-Eriksen
- Department of Clinical Microbiology, Aarhus University Hospital and Aarhus University, Denmark
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23
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Ashana DC, Welsh W, Preiss D, Sperling J, You H, Tu K, Carson SS, Hough C, White DB, Kerlin M, Docherty S, Johnson KS, Cox CE. Racial Differences in Shared Decision-Making About Critical Illness. JAMA Intern Med 2024; 184:424-432. [PMID: 38407845 PMCID: PMC10897823 DOI: 10.1001/jamainternmed.2023.8433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 12/18/2023] [Indexed: 02/27/2024]
Abstract
Importance Shared decision-making is the preferred method for evaluating complex tradeoffs in the care of patients with critical illness. However, it remains unknown whether critical care clinicians engage diverse patients and caregivers equitably in shared decision-making. Objective To compare critical care clinicians' approaches to shared decision-making in recorded conversations with Black and White caregivers of patients with critical illness. Design, Setting, and Participants This thematic analysis consisted of unstructured clinician-caregiver meetings audio-recorded during a randomized clinical trial of a decision aid about prolonged mechanical ventilation at 13 intensive care units in the US. Participants in meetings included critical care clinicians and Black or White caregivers of patients who underwent mechanical ventilation. The codebook included components of shared decision-making and known mechanisms of racial disparities in clinical communication. Analysts were blinded to caregiver race during coding. Patterns within and across racial groups were evaluated to identify themes. Data analysis was conducted between August 2021 and April 2023. Main Outcomes and Measures The main outcomes were themes describing clinician behaviors varying by self-reported race of the caregivers. Results The overall sample comprised 20 Black and 19 White caregivers for a total of 39 audio-recorded meetings with clinicians. The duration of meetings was similar for both Black and White caregivers (mean [SD], 23.9 [13.7] minutes vs 22.1 [11.2] minutes, respectively). Both Black and White caregivers were generally middle-aged (mean [SD] age, 47.6 [9.9] years vs 51.9 [8.8] years, respectively), female (15 [75.0%] vs 14 [73.7%], respectively), and possessed a high level of self-assessed health literacy, which was scored from 3 to 15 with lower scores indicating increasing health literacy (mean [SD], 5.8 [2.3] vs 5.3 [2.0], respectively). Clinicians conducting meetings with Black and White caregivers were generally young (mean [SD] age, 38.8 [6.6] years vs 37.9 [8.2] years, respectively), male (13 [72.2%] vs 12 [70.6%], respectively), and White (14 [77.8%] vs 17 [100%], respectively). Four variations in clinicians' shared decision-making behaviors by caregiver race were identified: (1) providing limited emotional support for Black caregivers, (2) failing to acknowledge trust and gratitude expressed by Black caregivers, (3) sharing limited medical information with Black caregivers, and (4) challenging Black caregivers' preferences for restorative care. These themes encompass both relational and informational aspects of shared decision-making. Conclusions and Relevance The results of this thematic analysis showed that critical care clinicians missed opportunities to acknowledge emotions and value the knowledge of Black caregivers compared with White caregivers. These findings may inform future clinician-level interventions aimed at promoting equitable shared decision-making.
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Affiliation(s)
- Deepshikha C. Ashana
- Department of Medicine, Duke University, Durham, North Carolina
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina
- Department of Population Health Sciences, Duke University, Durham, North Carolina
| | - Whitney Welsh
- Social Science Research Institute, Duke University, Durham, North Carolina
| | - Doreet Preiss
- Social Science Research Institute, Duke University, Durham, North Carolina
| | - Jessica Sperling
- Social Science Research Institute, Duke University, Durham, North Carolina
| | - HyunBin You
- School of Nursing, Duke University, Durham, North Carolina
| | - Karissa Tu
- School of Medicine, University of Washington, Seattle
| | | | - Catherine Hough
- Department of Medicine, Oregon Health and Science University, Portland
| | - Douglas B. White
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Meeta Kerlin
- Department of Medicine, University of Pennsylvania, Philadelphia
| | | | - Kimberly S. Johnson
- Department of Medicine, Duke University, Durham, North Carolina
- Geriatrics Research Education and Clinical Center (GRECC), Durham Veterans Affairs Healthcare System, Durham, North Carolina
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Altinger G, Sharma S, Maher CG, Cullen L, McCaffery K, Linder JA, Buchbinder R, Harris IA, Coiera E, Li Q, Howard K, Coggins A, Middleton PM, Gunja N, Ferguson I, Chan T, Tambree K, Varshney A, Traeger AC. Behavioural 'nudging' interventions to reduce low-value care for low back pain in the emergency department (NUDG-ED): protocol for a 2×2 factorial, before-after, cluster randomised trial. BMJ Open 2024; 14:e079870. [PMID: 38548366 PMCID: PMC10982715 DOI: 10.1136/bmjopen-2023-079870] [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: 09/15/2023] [Accepted: 02/08/2024] [Indexed: 04/02/2024] Open
Abstract
INTRODUCTION Opioids and imaging are considered low-value care for most people with low back pain. Yet around one in three people presenting to the emergency department (ED) will receive imaging, and two in three will receive an opioid. NUDG-ED aims to determine the effectiveness of two different behavioural 'nudge' interventions on low-value care for ED patients with low back pain. METHODS AND ANALYSIS NUDG-ED is a 2×2 factorial, open-label, before-after, cluster randomised controlled trial. The trial includes 8 ED sites in Sydney, Australia. Participants will be ED clinicians who manage back pain, and patients who are 18 years or over presenting to ED with musculoskeletal back pain. EDs will be randomly assigned to receive (i) patient nudges, (ii) clinician nudges, (iii) both interventions or (iv) no nudge control. The primary outcome will be the proportion of encounters in ED for musculoskeletal back pain where a person received a non-indicated lumbar imaging test, an opioid at discharge or both. We will require 2416 encounters over a 9-month study period (3-month before period and 6-month after period) to detect an absolute difference of 10% in use of low-value care due to either nudge, with 80% power, alpha set at 0.05 and assuming an intra-class correlation coefficient of 0.10, and an intraperiod correlation of 0.09. Patient-reported outcome measures will be collected in a subsample of patients (n≥456) 1 week after their initial ED visit. To estimate effects, we will use a multilevel regression model, with a random effect for cluster and patient, a fixed effect indicating the group assignment of each cluster and a fixed effect of time. ETHICS AND DISSEMINATION This study has ethical approval from Southwestern Sydney Local Health District Human Research Ethics Committee (2023/ETH00472). We will disseminate the results of this trial via media, presenting at conferences and scientific publications. TRIAL REGISTRATION NUMBER ACTRN12623001000695.
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Affiliation(s)
- Gemma Altinger
- Institute for Musculoskeletal Health, School of Public Health, Faculty of Medicine and Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
| | - Sweekriti Sharma
- Institute for Musculoskeletal Health, School of Public Health, Faculty of Medicine and Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
| | - Chris G Maher
- Institute for Musculoskeletal Health, School of Public Health, Faculty of Medicine and Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
| | - Louise Cullen
- Emergency and Trauma Centre, Royal Brisbane and Woman's Hospital Health Service District, Herston, Queensland, Australia
| | - Kirsten McCaffery
- Sydney Health Literacy Lab, School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Jeffrey A Linder
- Division of General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Rachelle Buchbinder
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Ian A Harris
- Institute for Musculoskeletal Health, School of Public Health, Faculty of Medicine and Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
- Whitlam Orthopaedic Research Centre, Ingham Institute, Sydney, New South Wales, Australia
| | - Enrico Coiera
- Centre for Health Informatics, Macquarie University, Sydney, New South Wales, Australia
| | - Qiang Li
- George Institute for Global Health, Sydney, New South Wales, Australia
| | - Kirsten Howard
- Menzies Centre for Health Policy and Economics, University of Sydney, Sydney, New South Wales, Australia
| | - Andrew Coggins
- Discipline of Emergency Medicine, The University of Sydney School of Medicine, Sydney, New South Wales, Australia
| | - Paul M Middleton
- South Western Emergency Research Institute, Ingham Institute for Applied Medical Research, Liverpool Hospital, Liverpool, New South Wales, Australia
- South West Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | - Naren Gunja
- Discipline of Emergency Medicine, The University of Sydney School of Medicine, Sydney, New South Wales, Australia
- Digital Health Solutions, Western Sydney Local Health District, Sydney, New South Wales, Australia
| | - Ian Ferguson
- South West Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
- Emergency Department, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Trevor Chan
- Emergency Care Institute, The Agency for Clinical Innovation, St Leonards Sydney, City of Willoughby, Australia
| | - Karen Tambree
- Consumer Advisor, The University of Sydney Institute for Musculoskeletal Health, Sydney, New South Wales, Australia
| | - Ajay Varshney
- Consumer Advisor, The University of Sydney Institute for Musculoskeletal Health, Sydney, New South Wales, Australia
| | - Adrian C Traeger
- Institute for Musculoskeletal Health, School of Public Health, Faculty of Medicine and Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
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Camard L, Liard R, Duverne S, Ibanez G, Skendi M. Consensus on relevant point-of-care ultrasound skills in General Practice: a two-round French Delphi study. BMC MEDICAL EDUCATION 2024; 24:341. [PMID: 38532436 DOI: 10.1186/s12909-024-05072-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 01/18/2024] [Indexed: 03/28/2024]
Abstract
CONTEXT Point-of-Care Ultrasound (POCUS) has become an important tool in the clinical practice of many specialties, but its use and impact in General Practice in France remains to be explored. OBJECTIVE The objective of this study is to obtain a consensus among experienced French general practitioners on a list of relevant POCUS skills in General Practice in 4 anatomical regions. METHOD We used a two-round Delphi method to obtain a consensus. An initial list of skills was drawn by conducting a literature review. To rate each skill, we used a nine-point Likert scale. An interactive meeting between experts took place between Delphi rounds. POCUS experts in General Practice were defined as general practitioners with theoretical training in ultrasound who regularly perform ultrasound, who have performed ultrasound for more than five years and/or are involved in providing ultrasound training. RESULTS 11 French general practitioners screened 83 skills in 4 anatomical regions: abdominal, urogenital, vascular, gynecology and obstetrics. An agreement was obtained for 36 POCUS skills as to their appropriateness in General Practice. There were 17 skills with a strong appropriate agreement (100% of "7-9" ratings) and 19 skills with a relative agreement (100% of "5-9" ratings). CONCLUSION These skills could serve as a basis for guidelines on the use and curriculum of POCUS in General Practice in France as well as in other countries with similar healthcare systems.
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Affiliation(s)
- Louis Camard
- Department of General Practice, Faculty of Medicine, Sorbonne University, Paris, France.
| | - Roxane Liard
- Department of General Practice, Faculty of Medicine, Sorbonne University, Paris, France
| | - Sophie Duverne
- Department of General Practice, Faculty of Medicine, Sorbonne University, Paris, France
| | - Gladys Ibanez
- Department of General Practice, Faculty of Medicine, Sorbonne University, Paris, France
- Pierre-Louis Institute of Epidemiology and Public Health, Paris, France
| | - Mariela Skendi
- Department of General Practice, Faculty of Medicine, Sorbonne University, Paris, France.
- Department of Adult Radiology, Necker Hospital, Paris, France.
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26
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Mills MF. Poker and Cardiology: Judging Our Decisions. Circulation 2024; 149:560-561. [PMID: 38377257 DOI: 10.1161/circulationaha.123.067366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
Affiliation(s)
- Marcos F Mills
- Children's Healthcare of Atlanta/Emory University School of Medicine, Atlanta, GA
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27
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Altabbaa G, Flemons W, Ocampo W, Babione JN, Kaufman J, Murphy S, Lamont N, Schaefer J, Boscan A, Stelfox HT, Conly J, Ghali WA. Deployment of a human-centred clinical decision support system for pulmonary embolism: evaluation of impact on quality of diagnostic decisions. BMJ Open Qual 2024; 13:e002574. [PMID: 38350673 PMCID: PMC10862276 DOI: 10.1136/bmjoq-2023-002574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 01/25/2024] [Indexed: 02/15/2024] Open
Abstract
Pulmonary embolism (PE) is a serious condition that presents a diagnostic challenge for which diagnostic errors often happen. The literature suggests that a gap remains between PE diagnostic guidelines and adherence in healthcare practice. While system-level decision support tools exist, the clinical impact of a human-centred design (HCD) approach of PE diagnostic tool design is unknown. DESIGN Before-after (with a preintervention period as non-concurrent control) design study. SETTING Inpatient units at two tertiary care hospitals. PARTICIPANTS General internal medicine physicians and their patients who underwent PE workups. INTERVENTION After a 6-month preintervention period, a clinical decision support system (CDSS) for diagnosis of PE was deployed and evaluated over 6 months. A CDSS technical testing phase separated the two time periods. MEASUREMENTS PE workups were identified in both the preintervention and CDSS intervention phases, and data were collected from medical charts. Physician reviewers assessed workup summaries (blinded to the study period) to determine adherence to evidence-based recommendations. Adherence to recommendations was quantified with a score ranging from 0 to 1.0 (the primary study outcome). Diagnostic tests ordered for PE workups were the secondary outcomes of interest. RESULTS Overall adherence to diagnostic pathways was 0.63 in the CDSS intervention phase versus 0.60 in the preintervention phase (p=0.18), with fewer workups in the CDSS intervention phase having very low adherence scores. Further, adherence was significantly higher when PE workups included the Wells prediction rule (median adherence score=0.76 vs 0.59, p=0.002). This difference was even more pronounced when the analysis was limited to the CDSS intervention phase only (median adherence score=0.80 when Wells was used vs 0.60 when Wells was not used, p=0.001). For secondary outcomes, using both the D-dimer blood test (42.9% vs 55.7%, p=0.014) and CT pulmonary angiogram imaging (61.9% vs 75.4%, p=0.005) was lower during the CDSS intervention phase. CONCLUSION A clinical decision support intervention with an HCD improves some aspects of the diagnostic decision, such as the selection of diagnostic tests and the use of the Wells probabilistic prediction rule for PE.
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Affiliation(s)
- Ghazwan Altabbaa
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ward Flemons
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Wrechelle Ocampo
- W21C Research and Innovation Centre, University of Calgary, Calgary, Alberta, Canada
| | | | - Jamie Kaufman
- W21C Research and Innovation Centre, University of Calgary, Calgary, Alberta, Canada
| | - Sydney Murphy
- W21C Research and Innovation Centre, University of Calgary, Calgary, Alberta, Canada
| | - Nicole Lamont
- W21C Research and Innovation Centre, University of Calgary, Calgary, Alberta, Canada
| | - Jeffrey Schaefer
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Alejandra Boscan
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Henry T Stelfox
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - John Conly
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - William A Ghali
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Sinuraya RK, Nuwarda RF, Postma MJ, Suwantika AA. Vaccine hesitancy and equity: lessons learned from the past and how they affect the COVID-19 countermeasure in Indonesia. Global Health 2024; 20:11. [PMID: 38321478 PMCID: PMC10845639 DOI: 10.1186/s12992-023-00987-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 11/04/2023] [Indexed: 02/08/2024] Open
Abstract
INTRODUCTION Indonesia has made progress in increasing vaccine coverage, but equitable access remains challenging, especially in remote areas. Despite including vaccines in the National Immunization Program (NIP), coverage has not met WHO and UNICEF targets, with childhood immunization decreasing during the COVID-19 pandemic. COVID-19 vaccination has also experienced hesitancy, slowing efforts to end the pandemic. SCOPE This article addresses the issue of vaccine hesitancy and its impact on vaccination initiatives amidst the COVID-19 pandemic. This article utilizes the vaccine hesitancy framework to analyze previous outbreaks of vaccine-preventable diseases and their underlying causes, ultimately providing recommendations for addressing the current situation. The analysis considers the differences between the pre-pandemic circumstances and the present and considers the implementation of basic and advanced strategies. KEY FINDINGS AND CONCLUSION Vaccine hesitancy is a significant challenge in the COVID-19 pandemic, and public health campaigns and community engagement efforts are needed to promote vaccine acceptance and uptake. Efforts to address vaccine hesitancy promote trust in healthcare systems and increase the likelihood of individuals seeking preventive health services. Vaccine hesitancy requires a comprehensive, culturally sensitive approach that considers local contexts and realities. Strategies should be tailored to specific cultural and societal contexts and monitored and evaluated.
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Affiliation(s)
- Rano K Sinuraya
- Unit of Global Health, Department of Health Sciences, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Jalan Ir. Soekarno KM 21, Jatinangor, Sumedang, West Java, 45363, Indonesia
- Center of Excellence for Pharmaceutical Care Innovation, Universitas Padjadjaran, Sumedang, West Java, Indonesia
| | - Rina F Nuwarda
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Department of Pharmaceutical Analysis and Medicinal Chemistry, Faculty of Pharmacy, Universitas Padjadjaran, Sumedang, West Java, Indonesia
| | - Maarten J Postma
- Unit of Global Health, Department of Health Sciences, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
- Center of Excellence for Pharmaceutical Care Innovation, Universitas Padjadjaran, Sumedang, West Java, Indonesia
- Department of Economics, Econometrics & Finance, Faculty of Economics & Business, University of Groningen, Groningen, the Netherlands
| | - Auliya A Suwantika
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Jalan Ir. Soekarno KM 21, Jatinangor, Sumedang, West Java, 45363, Indonesia.
- Center of Excellence for Pharmaceutical Care Innovation, Universitas Padjadjaran, Sumedang, West Java, Indonesia.
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O'Brien K, Zhang B, Anderl E, Kothari S. Special Considerations in Behavioral Assessments for Disorders of Consciousness. Phys Med Rehabil Clin N Am 2024; 35:93-108. [PMID: 37993196 DOI: 10.1016/j.pmr.2023.07.007] [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: 11/24/2023]
Abstract
Behavioral assessment remains the cornerstone of the clinical evaluation of disorders of consciousness (DoC). Because the basic approach to these evaluations has been extensively reviewed elsewhere, this article focuses on special considerations in the behavioral assessment of patients with a DoC. All therapy disciplines (physical therapy/occupational therapy/speech language pathologist) have a significant role to play and other staff and family members should also be encouraged to share their observations. Finally, the assessment with standardized scales should be supplemented by qualitative behavioral observations as well as, when appropriate, an individualized quantitative behavioral assessment.
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Affiliation(s)
- Katherine O'Brien
- TIRR Disorders of Consciousness Program, TIRR Memorial Hermann Hospital, 1333 Moursund Street, Houston, TX 77030, USA; Department of Physical Medicine and Rehabilitation, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, USA; H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX 77030, USA.
| | - Bei Zhang
- Division of Physical Medicine and Rehabilitation, Department of Neurology, Texas Tech University Health Sciences Center, 3601 4th Street, STOP 8321, Lubbock, TX 79430, USA. https://twitter.com/BeiZhangMD
| | - Elizabeth Anderl
- TIRR Disorders of Consciousness Program, TIRR Memorial Hermann Hospital, 1333 Moursund Street, Houston, TX 77030, USA
| | - Sunil Kothari
- TIRR Disorders of Consciousness Program, TIRR Memorial Hermann Hospital, 1333 Moursund Street, Houston, TX 77030, USA; H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX 77030, USA
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Sawyer KE, Opel DJ. Shared Decision-Making in Pediatrics. Pediatr Clin North Am 2024; 71:39-48. [PMID: 37973305 DOI: 10.1016/j.pcl.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
This article briefly reviews a 4-step process for implementing shared decision-making (SDM) in pediatrics. The authors address difficulties with determining whether SDM should occur and comment on how the SDM process relates to, and may be conflated with, other decision-making models that leverage similar patient-centered and family-centered communication strategies.
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Affiliation(s)
- Kimberly E Sawyer
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital Palliative Care Team, 6621 Fannin Street, Suite W.1990, Houston, TX 77030, USA.
| | - Douglas J Opel
- Department of Pediatrics, School of Medicine, University of Washington, Seattle, WA, USA; Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, 1900 9th Avenue, JMB 6, Seattle, WA 98101, USA
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Watari T, Gupta A, Amano Y, Tokuda Y. Japanese Internists' Most Memorable Diagnostic Error Cases: A Self-reflection Survey. Intern Med 2024; 63:221-229. [PMID: 37286507 PMCID: PMC10864084 DOI: 10.2169/internalmedicine.1494-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 04/23/2023] [Indexed: 06/09/2023] Open
Abstract
Objective The etiologies of diagnostic errors among internal medicine physicians are unclear. To understand the causes and characteristics of diagnostic errors through reflection by those involved in them. Methods We conducted a cross-sectional study using a web-based questionnaire in Japan in January 2019. Over a 10-day period, a total of 2,220 participants agreed to participate in the study, of whom 687 internists were included in the final analysis. Participants were asked about their most memorable diagnostic error cases, in which the time course, situational factors, and psychosocial context could be most vividly recalled and where the participant provided care. We categorized diagnostic errors and identified contributing factors (i.e., situational factors, data collection/interpretation factors, and cognitive biases). Results Two-thirds of the identified diagnostic errors occurred in the clinic or emergency department. Errors were most frequently categorized as wrong diagnoses, followed by delayed and missed diagnoses. Errors most often involved diagnoses related to malignancy, circulatory system disorders, or infectious diseases. Situational factors were the most cited error cause, followed by data collection factors and cognitive bias. Common situational factors included limited consultation during office hours and weekends and barriers that prevented consultation with a supervisor or another department. Conclusion Internists reported situational factors as a significant cause of diagnostic errors. Other factors, such as cognitive biases, were also evident, although the difference in clinical settings may have influenced the proportions of the etiologies of the errors that were observed. Furthermore, wrong, delayed, and missed diagnoses may have distinctive associated cognitive biases.
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Affiliation(s)
- Takashi Watari
- General Medicine Center, Shimane University Hospital, Japan
- Medicine Service, VA Ann Arbor Healthcare System, USA
- Department of Medicine, University of Michigan Medical School, USA
| | - Ashwin Gupta
- Medicine Service, VA Ann Arbor Healthcare System, USA
- Department of Medicine, University of Michigan Medical School, USA
| | - Yu Amano
- Faculty of Medicine, Shimane University, Japan
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Mehta SJ, McDonald C, Reitz C, Kastuar S, Snider CK, Okorie E, McNelis K, Shaikh H, Cook TS, Goldberg DS, Rothstein K. A randomized trial of mailed outreach with behavioral economic interventions to improve liver cancer surveillance. Hepatol Commun 2024; 8:e0349. [PMID: 38099859 PMCID: PMC10727671 DOI: 10.1097/hc9.0000000000000349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 11/08/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Surveillance rates for HCC remain limited in patients with cirrhosis. We evaluated whether opt-out mailed outreach increased uptake with or without a $20 unconditional incentive. METHODS This was a pragmatic randomized controlled trial in an urban academic health system including adult patients with cirrhosis or advanced fibrosis, at least 1 visit to a specialty practice in the past 2 years and no surveillance in the last 7 months. Patients were randomized in a 1:2:2 ratio to (1) usual care, (2) a mailed letter with a signed order for an ultrasound, or (3) a mailed letter with an order and a $20 unconditional incentive. The main outcome was the proportion with completion of ultrasound within 6 months. RESULTS Among the 562 patients included, the mean age was 62.1 (SD 11.1); 56.8% were male, 51.1% had Medicare, and 40.6% were Black. At 6 months, 27.6% (95% CI: 19.5-35.7) completed ultrasound in the Usual care arm, 54.5% (95% CI: 47.9-61.0) in the Letter + Order arm, and 54.1% (95% CI: 47.5-60.6) in the Letter + Order + Incentive arm. There was a significant increase in the Letter + Order arm compared to Usual care (absolute difference of 26.9%; 95% CI: 16.5-37.3; p<0.001), but no significant increase in the Letter + Order + Incentive arm compared to Letter + Order (absolute difference of -0.4; 95% CI: -9.7 to 8.8; p=0.93). CONCLUSIONS There was an increase in HCC surveillance from mailed outreach with opt-out framing and a signed order slip, but no increase in response to the financial incentive.
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Affiliation(s)
- Shivan J. Mehta
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia, USA
| | - Caitlin McDonald
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia, USA
| | - Catherine Reitz
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia, USA
| | - Shivani Kastuar
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | | | - Evelyn Okorie
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia, USA
| | - Kiernan McNelis
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia, USA
| | - Hamzah Shaikh
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Tessa S. Cook
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - David S. Goldberg
- Department of Medicine, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Kenneth Rothstein
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
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Waters EA, Pachur T, Pogge G, Hunleth J, Webster GD, Shepperd JA. Linking cognitive and affective heuristic cues to interpersonal risk perceptions and behavior. RISK ANALYSIS : AN OFFICIAL PUBLICATION OF THE SOCIETY FOR RISK ANALYSIS 2023; 43:2610-2630. [PMID: 36781299 PMCID: PMC10423305 DOI: 10.1111/risa.14101] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 01/03/2023] [Accepted: 01/05/2023] [Indexed: 06/18/2023]
Abstract
People often use cognitive and affective heuristics when judging the likelihood of a health outcome and making health decisions. However, little research has examined how heuristics shape risk perceptions and behavior among people who make decisions on behalf of another person. We examined associations between heuristic cues and caregivers' perceptions of their child's asthma risk, the frequency of caregivers' asthma management behaviors, and child health outcomes. We used Ipsos KnowledgePanel to recruit 814 U.S. adult caregivers of children with asthma of the age <18 years. Participants completed a survey at baseline (T1) and 3 months later (T2). Caregivers who, at T1, reported greater negative affect about their child's asthma (affect heuristic cue), greater ease of imagining their child experiencing asthma symptoms (availability heuristic cue), and greater perceived similarity between their child and a child who has ever experienced asthma symptoms (representativeness heuristic cue) reported statistically significantly (p < 0.05) higher interpersonal perceived risk of their child having an exacerbation or uncontrolled asthma at T1. They also indicated at T2 that their child had poorer asthma control and more frequent exacerbations. Greater T1 negative affect was associated with more frequent T2 actions to reduce inflammation, manage triggers, and manage symptoms, and with poorer T2 child health outcomes. Heuristic cues are likely important for interpersonal-not just personal-risk perceptions. However, the interrelationship between caregivers' ratings of heuristic cues (in particular, negative affect) and risk judgments may signify a struggle with managing their child's asthma and need for extra support from health care providers or systems.
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Affiliation(s)
- Erika A. Waters
- Washington University in St. Louis, Saint Louis, Missouri, USA
| | | | | | - Jean Hunleth
- Washington University in St. Louis, Saint Louis, Missouri, USA
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Amoretti MC, Lalumera E. Unveiling the interplay between evidence, values and cognitive biases. The case of the failure of the AstraZeneca COVID-19 vaccine. J Eval Clin Pract 2023; 29:1294-1301. [PMID: 37515407 DOI: 10.1111/jep.13903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 07/06/2023] [Accepted: 07/11/2023] [Indexed: 07/30/2023]
Abstract
This paper depicts a Covid science case, that of the AstraZeneca Vaxzevria vaccine, with specific focus on what happened in Italy. Given that we believe acknowledging the role of non-evidential factors in medicine is an important insight into the recent philosophy of science, we illustrate how in the case of Vaxzevria, the interplay between facts, values (both epistemic and non-epistemic) and cognitive biases may have possibly led to different institutional decisions based on the same evidence. The structure of the paper is as follows. First, we provide a glossary of the relevant terms involved, that is to say, epistemic values, non-epistemic values and cognitive biases. Second, we sketch a timeline of Vaxzevria's approvals and suspensions by relevant institutional healthcare authorities with special focus on Italy and the Italian Medicines Agency. Then we show the interplay between the evidence base, epistemic as well as non-epistemic values and cognitive biases using a narrative review of political decisions along with newspaper and social media content pertaining to Vaxzevria. We briefly compare Italy with other European countries to show that different political decisions were made on the basis of the same evidence.
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35
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Ropers FG, Rietveld S, Rings EHHM, Bossuyt PMM, van Bodegom-Vos L, Hillen MA. Diagnostic testing in children: A qualitative study of pediatricians' considerations. J Eval Clin Pract 2023; 29:1326-1337. [PMID: 37221991 DOI: 10.1111/jep.13867] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 05/02/2023] [Accepted: 05/04/2023] [Indexed: 05/25/2023]
Abstract
AIMS AND OBJECTIVES Studies in adult medicine have shown that physicians base testing decisions on the patient's clinical condition but also consider other factors, including local practice or patient expectations. In pediatrics, physicians and parents jointly decide on behalf of a (young) child. This might demand more explicit and more complex deliberations, with sometimes conflicting interests. We explored pediatricians' considerations in diagnostic test ordering and the factors that influence their deliberation. METHOD We performed in-depth, semistructured interviews with a purposively selected heterogeneous sample of 20 Dutch pediatricians. We analyzed transcribed interviews inductively using a constant comparative approach, and clustered data across interviews to derive common themes. RESULTS Pediatricians perceived test-related burden in children higher compared with adults, and reported that avoiding an unjustified burden causes them to be more restrictive and deliberate in test ordering. They felt conflicted when parents desired testing or when guidelines recommended diagnostic tests pediatricians perceived as unnecessary. When parents demanded testing, they would explore parental concern, educate parents about harms and alternative explanations of symptoms, and advocate watchful waiting. Yet they reported sometimes performing tests to appease parents or to comply with guidelines, because of feared personal consequences in the case of adverse outcomes. CONCLUSION We obtained an overview of the considerations that are weighed in pediatric test decisions. The comparatively strong focus on prevention of harm motivates pediatricians to critically appraise the added value of testing and drivers of low-value testing. Pediatricians' relatively restrictive approach to testing could provide an example for other disciplines. Improved guidelines and physician and patient education could help to withstand the perceived pressure to test.
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Affiliation(s)
- Fabienne G Ropers
- Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Sophie Rietveld
- Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Edmond H H M Rings
- Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
- Department of Pediatrics, Sophia Children's Hospital, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Patrick M M Bossuyt
- Amsterdam University Medical Centers, University of Amsterdam, Epidemiology & Data Science, Amsterdam, The Netherlands
- Amsterdam Public Health, Methodology, Amsterdam, The Netherlands
| | - Leti van Bodegom-Vos
- Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Marij A Hillen
- Amsterdam University Medical Centers, location AMC, Amsterdam Public Health, Medical Psychology, Amsterdam, The Netherlands
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Hepburn J. Diagnostic uncertainty and axial spondyloarthropathy: A case for cognitive debiasing through practice-based learning and improvement activity. Musculoskeletal Care 2023; 21:1463-1469. [PMID: 37776078 DOI: 10.1002/msc.1818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 08/29/2023] [Accepted: 09/03/2023] [Indexed: 10/01/2023]
Affiliation(s)
- Jordan Hepburn
- Musculoskeletal (MSK) GP Advanced Practice Physiotherapy Service, Edinburgh Health & Social Care Partnership, NHS Lothian, Edinburgh, UK
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Vassy JL, Kerman BJ, Harris EJ, Lemke AA, Clayman ML, Antwi AA, MacIsaac K, Yi T, Brunette CA. Perceived benefits and barriers to implementing precision preventive care: Results of a national physician survey. Eur J Hum Genet 2023; 31:1309-1316. [PMID: 36807341 PMCID: PMC10620193 DOI: 10.1038/s41431-023-01318-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 01/25/2023] [Accepted: 02/06/2023] [Indexed: 02/22/2023] Open
Abstract
Polygenic risk scores (PRS) may improve risk-stratification in preventive care. Their clinical implementation will depend on primary care physicians' (PCPs) uptake. We surveyed PCPs in a national physician database about the perceived clinical utility, benefits, and barriers to the use of PRS in preventive care. Among 367 respondents (participation rate 96.3%), mean (SD) age was 54.9 (12.9) years, 137 (37.3%) were female, and mean (SD) time since medical school graduation was 27.2 (13.3) years. Respondents reported greater perceived utility for more clinical action (e.g., earlier or more intensive screening, preventive medications, or lifestyle modification) for patients with high-risk PRS than for delayed or discontinued prevention actions for low-risk patients (p < 0.001). Respondents most often chose out-of-pocket costs (48%), lack of clinical guidelines (24%), and insurance discrimination concerns (22%) as extreme barriers. Latent class analysis identified 3 subclasses of respondents. Skeptics (n = 83, 22.6%) endorsed less agreement with individual clinical utilities, saw patient anxiety and insurance discrimination as significant barriers, and agreed less often that PRS could help patients make better health decisions. Learners (n = 134, 36.5%) and enthusiasts (n = 150, 40.9%) expressed similar levels of agreement that PRS had utility for preventive actions and that PRS could be useful for patient decision-making. Compared with enthusiasts, however, learners perceived greater barriers to the clinical use of PRS. Overall results suggest that PCPs generally endorse using PRS to guide medical decision-making about preventive care, and barriers identified suggest interventions to address their needs and concerns.
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Affiliation(s)
- Jason L Vassy
- Harvard Medical School, Boston, MA, USA.
- Veterans Affairs Boston Healthcare System, Boston, MA, USA.
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.
- Precision Population Health, Ariadne Labs, Boston, MA, USA.
| | - Benjamin J Kerman
- Harvard Medical School, Boston, MA, USA
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Elizabeth J Harris
- Harvard Medical School, Boston, MA, USA
- Veterans Affairs Boston Healthcare System, Boston, MA, USA
| | - Amy A Lemke
- Norton Children's Research Institute, Affiliated with the University of Louisville School of Medicine, Louisville, KY, USA
| | - Marla L Clayman
- UMass Chan Medical School, Department of Population and Quantitative Health Sciences, Worcester, MA, USA
- Edith Nourse Rogers Memorial Veterans' Hospital, Bedford, MA, USA
| | - Ashley A Antwi
- Veterans Affairs Boston Healthcare System, Boston, MA, USA
| | - Katharine MacIsaac
- Harvard Medical School, Boston, MA, USA
- Veterans Affairs Boston Healthcare System, Boston, MA, USA
| | - Thomas Yi
- Veterans Affairs Boston Healthcare System, Boston, MA, USA
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Vicente L, Matute H. Humans inherit artificial intelligence biases. Sci Rep 2023; 13:15737. [PMID: 37789032 PMCID: PMC10547752 DOI: 10.1038/s41598-023-42384-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 09/09/2023] [Indexed: 10/05/2023] Open
Abstract
Artificial intelligence recommendations are sometimes erroneous and biased. In our research, we hypothesized that people who perform a (simulated) medical diagnostic task assisted by a biased AI system will reproduce the model's bias in their own decisions, even when they move to a context without AI support. In three experiments, participants completed a medical-themed classification task with or without the help of a biased AI system. The biased recommendations by the AI influenced participants' decisions. Moreover, when those participants, assisted by the AI, moved on to perform the task without assistance, they made the same errors as the AI had made during the previous phase. Thus, participants' responses mimicked AI bias even when the AI was no longer making suggestions. These results provide evidence of human inheritance of AI bias.
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Affiliation(s)
- Lucía Vicente
- Department of Psychology, Deusto University, Avenida Universidades 24, 48007, Bilbao, Spain
| | - Helena Matute
- Department of Psychology, Deusto University, Avenida Universidades 24, 48007, Bilbao, Spain.
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Lissak IA, Edlow BL, Rosenthal E, Young MJ. Ethical Considerations in Neuroprognostication Following Acute Brain Injury. Semin Neurol 2023; 43:758-767. [PMID: 37802121 DOI: 10.1055/s-0043-1775597] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/08/2023]
Abstract
Neuroprognostication following acute brain injury (ABI) is a complex process that involves integrating vast amounts of information to predict a patient's likely trajectory of neurologic recovery. In this setting, critically evaluating salient ethical questions is imperative, and the implications often inform high-stakes conversations about the continuation, limitation, or withdrawal of life-sustaining therapy. While neuroprognostication is central to these clinical "life-or-death" decisions, the ethical underpinnings of neuroprognostication itself have been underexplored for patients with ABI. In this article, we discuss the ethical challenges of individualized neuroprognostication including parsing and communicating its inherent uncertainty to surrogate decision-makers. We also explore the population-based ethical considerations that arise in the context of heterogenous prognostication practices. Finally, we examine the emergence of artificial intelligence-aided neuroprognostication, proposing an ethical framework relevant to both modern and longstanding prognostic tools.
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Affiliation(s)
- India A Lissak
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Brian L Edlow
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, Massachusetts
| | - Eric Rosenthal
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Michael J Young
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
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Miranda SP, Morris RS, Rabas M, Creutzfeldt CJ, Cooper Z. Early Shared Decision-Making for Older Adults with Traumatic Brain Injury: Using Time-Limited Trials and Understanding Their Limitations. Neurocrit Care 2023; 39:284-293. [PMID: 37349599 DOI: 10.1007/s12028-023-01764-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 05/11/2023] [Indexed: 06/24/2023]
Abstract
Older adults account for a disproportionate share of the morbidity and mortality after traumatic brain injury (TBI). Predicting functional and cognitive outcomes for individual older adults after TBI is challenging in the acute phase of injury. Given that neurologic recovery is possible and uncertain, life-sustaining therapy may be pursued initially, even if for some, there is a risk of survival to an undesired level of disability or dependence. Experts recommend early conversations about goals of care after TBI, but evidence-based guidelines for these discussions or for the optimal method for communicating prognosis are limited. The time-limited trial (TLT) model may be an effective strategy for managing prognostic uncertainty after TBI. TLTs can provide a framework for early management: specific treatments or procedures are used for a defined period of time while monitoring for an agreed-upon outcome. Outcome measures, including signs of worsening and improvement, are defined at the outset of the trial. In this Viewpoint article, we discuss the use of TLTs for older adults with TBI, their potential benefits, and current challenges to their application. Three main barriers limit the implementation of TLTs in these scenarios: inadequate models for prognostication; cognitive biases faced by clinicians and surrogate decision-makers, which may contribute to prognostic discordance; and ambiguity regarding appropriate endpoints for the TLT. Further study is needed to understand clinician behaviors and surrogate preferences for prognostic communication and how to optimally integrate TLTs into the care of older adults with TBI.
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Affiliation(s)
- Stephen P Miranda
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, USA.
- Perelman Center for Advanced Medicine, 15 South Tower, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA.
| | - Rachel S Morris
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Mackenzie Rabas
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Zara Cooper
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
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Jala S, Fry M, Elliott R. Cognitive bias during clinical decision-making and its influence on patient outcomes in the emergency department: A scoping review. J Clin Nurs 2023; 32:7076-7085. [PMID: 37605250 DOI: 10.1111/jocn.16845] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 06/16/2023] [Accepted: 07/31/2023] [Indexed: 08/23/2023]
Abstract
BACKGROUND An integral part of clinical practice is decision-making. Yet there is widespread acceptance that there is evidence of cognitive bias within clinical practice among nurses and physicians. However, how cognitive bias among emergency nurses and physicians' decision-making influences patient outcomes remains unclear. AIM The aim of this review was to systematically synthesise research exploring the emergency nurses' and physicians' cognitive bias in decision-making and its influence on patient outcomes. METHODS This scoping review was guided by the PRISMA Extension for Scoping Reviews. The databases searched included CINAHL, MEDLINE, Web of Science and PubMed. No date limits were applied. The Patterns, Advances, Gaps, Evidence for practice and Research recommendation (PAGER) framework was used to guide the discussion. RESULTS The review included 18 articles, consisting of 10 primary studies (nine quantitative and one qualitative) and eight literature reviews. Of the 18 articles, nine investigated physicians, five articles examined nurses, and four both physicians and nurses with sample sizes ranging from 13 to 3547. Six primary studies were cross-sectional and five used hypothetical scenarios, and one real-world assessment. Three were experimental studies. Twenty-nine cognitive biases were identified with Implicit bias (n = 12) most frequently explored, followed by outcome bias (n = 4). Results were inconclusive regarding the influence of biases on treatment decisions and patient outcomes. Four key themes were identified; (i) cognitive biases among emergency clinicians; (ii) measurement of cognitive bias; (iii) influence of cognitive bias on clinical decision-making; and (iv) association between emergency clinicians' cognitive bias and patient outcomes. CONCLUSIONS This review identified that cognitive biases were present among emergency nurses and physicians during clinical decision-making, but it remains unclear how cognitive bias influences patient outcomes. Further research examining emergency clinicians' cognitive bias is required. RELEVANCE TO CLINICAL PRACTICE Awareness of emergency clinicians' own cognitive biases may result to the provision of equity in care. NO PATIENT OR PUBLIC CONTRIBUTION IN THIS REVIEW We intend to disseminate the results through publication in a peer-reviewed journals and conference presentations.
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Affiliation(s)
- Sheila Jala
- Faculty of Health, School of Nursing and Midwifery, University of Technology Sydney, Sydney, New South Wales, Australia
- Neurology Department, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Margaret Fry
- Faculty of Health, School of Nursing and Midwifery, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Rosalind Elliott
- Faculty of Health, School of Nursing and Midwifery, University of Technology Sydney, Sydney, New South Wales, Australia
- Nursing and Midwifery Research Centre, Nursing and Midwifery Directorate, Northern Sydney Local Health District, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- Department of Intensive Care Medicine, Royal North Shore Hospital, St Leonards, New South Wales, Australia
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Schroeder HS, Israeli A, Liebergall M(I, Or O, Abu Ahmed W, Paltiel O, Justo D, Zimlichman E. Perception of Goals and Expected Outcomes in Older Hip Fracture Patients and Their Medical Staff: A Cross Sectional Study. Geriatr Orthop Surg Rehabil 2023; 14:21514593231202735. [PMID: 37744458 PMCID: PMC10517609 DOI: 10.1177/21514593231202735] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/26/2023] Open
Abstract
Background Goal-oriented patientcare is a key element in qualityhealthcare. Medical-caregiver's (MC) are expected to generate a shared decision-making process with patients regarding goals and expected health-outcomes. Hip-fracture patients (HFP) are usually older-adults with multiple health-conditions, necessitating that agreed-upon goals regarding the rehabilitation process, take these conditions into consideration. This topic has yet to be investigated by pairing and comparing the perception of expected outcomes and therapeutic goals of multidisciplinary MCs and their HF patient's. Our aim was to assess in a quantitative method whether HFPs and their multidisciplinary MCs agree upon target health-outcomes and their most important goals as they are reflected in the SF12 questionnaire. Methods This was a cross-sectional, multi-center, study of HFPs and their MCs. Patients and MCs were asked to rate their top three most important goals for rehabilitation from the SF12 eight subscales: physical functioning, physical role limitation, bodily pain, general health, vitality, social functioning, emotional role limitation and mental health, and indicate their expected outcome. Descriptive statistics and mixed effect logistic-regression were used to compare concordance of the ratings. Agreement between patients and MCs was assessed using interclass coefficients (ICCs). Results A total of 378 ratings were collected from 52 patients, 12 nurses, 12 physicians and 6 paramedical personnel. Each patient had between 3 and 9 raters. Patients considered physical functioning and physical role limitation more important than did MCs. Physicians and nurses emphasized the importance of bodily pain while patients referred to it as relatively less significant. The total ICC was low (2%) indicating poor agreement between MCs and patients. With the exception of physical-functioning, MCs predicted a less optimistic outcome in all of the SF12's subscales in comparison to HFPs. Conclusion Effective intervention in HFPs requires constructive communication between MCs and patients. The study suggests that caregivers have an insufficient understanding of the expectations of HFPs. More effective communication channels are required in order to better understand HFPs' needs and expectations.
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Affiliation(s)
- Hanna S. Schroeder
- Department of Nursing at the Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- Braun School of Public Health, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Avi Israeli
- Dr. Julien Rozan Professor of Healthcare, Hebrew University – Hadassah Medical School, Jerusalem, Israel
- Hadassah University Medical Center, Jerusalem, Israel
- Israel Ministry of Health, Jerusalem, Israel
| | - Meir (Iri) Liebergall
- Orthopedic Department of Surgery, Hadassah Medical Center, Hebrew University, Jerusalem, Israel
| | - Omer Or
- Orthopedic Department of Surgery, Hadassah Medical Center, Hebrew University, Jerusalem, Israel
| | - Wiessam Abu Ahmed
- Braun School of Public Health, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ora Paltiel
- Braun School of Public Health, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Dan Justo
- Geriatrics Division, Sheba Medical Center, Ramat-Gan, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Eyal Zimlichman
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- Central Management, Sheba Medical Center, Ramat-Gan, Israel
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Serletti L, Dutcher L, Degnan KO, Szymczak JE, Cluzet V, David MZ, Cressman L, Glassman LW, Hamilton KW. Analysis of seasonal variation of antibiotic prescribing for respiratory tract diagnoses in primary care practices. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2023; 3:e147. [PMID: 37771744 PMCID: PMC10523546 DOI: 10.1017/ash.2023.418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 06/15/2023] [Accepted: 06/17/2023] [Indexed: 09/30/2023]
Abstract
Objective To determine antibiotic prescribing appropriateness for respiratory tract diagnoses (RTD) by season. Design Retrospective cohort study. Setting Primary care practices in a university health system. Patients Patients who were seen at an office visit with diagnostic code for RTD. Methods Office visits for the entire cohort were categorized based on ICD-10 codes by the likelihood that an antibiotic was indicated (tier 1: always indicated; tier 2: sometimes indicated; tier 3: rarely indicated). Medical records were reviewed for 1,200 randomly selected office visits to determine appropriateness. Based on this reference standard, metrics and prescriber characteristics associated with inappropriate antibiotic prescribing were determined. Characteristics of antibiotic prescribing were compared between winter and summer months. Results A significantly greater proportion of RTD visits had an antibiotic prescribed in winter [20,558/51,090 (40.2%)] compared to summer months [11,728/38,537 (30.4%)][standardized difference (SD) = 0.21]. A significantly greater proportion of winter compared to summer visits was associated with tier 2 RTDs (29.4% vs 23.4%, SD = 0.14), but less tier 3 RTDs (68.4% vs 74.4%, SD = 0.13). A greater proportion of visits in winter compared to summer months had an antibiotic prescribed for tier 2 RTDs (80.2% vs 74.2%, SD = 0.14) and tier 3 RTDs (22.9% vs 16.2%, SD = 0.17). The proportion of inappropriate antibiotic prescribing was higher in winter compared to summer months (72.4% vs 62.0%, P < .01). Conclusions Increases in antibiotic prescribing for RTD visits from summer to winter were likely driven by shifts in diagnoses as well as increases in prescribing for certain diagnoses. At least some of this increased prescribing was inappropriate.
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Affiliation(s)
- Lacey Serletti
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Lauren Dutcher
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Kathleen O. Degnan
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Julia E. Szymczak
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Valerie Cluzet
- Division of Infectious Diseases, Nuvance Health, Poughkeepsie, NY, USA
| | - Michael Z. David
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Leigh Cressman
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Keith W. Hamilton
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
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Walsh JP, Hsiao MS, Rosevear L, McDermott R, Gupta S, Watson TS. Orthopaedic knee scooter-related injury: prevalence and patient safety perception in a prospective cohort with exploratory risk factor analysis. J Orthop Surg Res 2023; 18:649. [PMID: 37658457 PMCID: PMC10474665 DOI: 10.1186/s13018-023-04124-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 08/23/2023] [Indexed: 09/03/2023] Open
Abstract
BACKGROUND There is a paucity of research investigating the harms associated with orthopaedic knee scooter (OKS) use and patient safety perceptions. This prospective study aimed to define the prevalence of OKS-related injuries, describe the patient perceptions of OKS safety, and identify potential risk factors. METHODS This study was conducted at a single foot and ankle fellowship-trained surgeon's community-based clinic from 6/2020 to 4/2021 and enrolled 134 patients. Our primary outcome was an OKS-related event (injury or fall) and informed an a priori power analysis. Point estimate of association magnitude was calculated as an odds ratio (OR) for statistically and clinically significant associations. RESULTS There were 118 (88%) patients eligible for analysis; fourteen enrolled patients did not use OKS, and two withdrew. The prevalence of patient falls was 37% (44/118), and the prevalence of patient injury was 15% (18/118). Four percent of patients would not recommend OKS and 8% would not use an OKS again. Sedentary lifestyle increased risk (OR = 4.67, 1.52-14.35 95 CI) for OKS-related injury. CONCLUSIONS Despite a high prevalence of patient falls (37%), there is a low prevalence of injury (15%) and a favorable perception of OKS safety. Sedentary lifestyles may be a risk factor for OKS-related injury and should be considered in the development of a risk model.
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Affiliation(s)
- John P Walsh
- Department of Orthopaedic Surgery, Valley Hospital Medical Center, 620 Shadow Lane, Suite 450, Las Vegas, NV, 89121, USA.
- The Foot and Ankle Institute at Desert Orthopaedic Center, Las Vegas, NV, USA.
| | - Mark S Hsiao
- The Foot and Ankle Institute at Desert Orthopaedic Center, Las Vegas, NV, USA
| | - Landon Rosevear
- Department of Orthopaedic Surgery, Valley Hospital Medical Center, 620 Shadow Lane, Suite 450, Las Vegas, NV, 89121, USA
| | - Ryland McDermott
- The Foot and Ankle Institute at Desert Orthopaedic Center, Las Vegas, NV, USA
- Kirk Kerkorian School of Medicine at UNLV, Las Vegas, NV, USA
| | - Shivali Gupta
- Department of Orthopaedic Surgery, Valley Hospital Medical Center, 620 Shadow Lane, Suite 450, Las Vegas, NV, 89121, USA
| | - Troy S Watson
- Department of Orthopaedic Surgery, Valley Hospital Medical Center, 620 Shadow Lane, Suite 450, Las Vegas, NV, 89121, USA
- The Foot and Ankle Institute at Desert Orthopaedic Center, Las Vegas, NV, USA
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Siller S, Kunz M, Lauseker M, Dimitriadis K, Dorn F, Tonn JC, Schichor C. The impact of initial counselling for patients' decision-making and the accuracy of interdisciplinary neurovascular board evaluation in elective treatment of unruptured intracranial aneurysms - a German single-centre retrospective study. Clin Neurol Neurosurg 2023; 232:107896. [PMID: 37454599 DOI: 10.1016/j.clineuro.2023.107896] [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] [Received: 05/23/2023] [Revised: 07/10/2023] [Accepted: 07/11/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVE Interdisciplinary-neurovascular-boards (INVB) are deemed to find the patient's optimum treatment-modality in elective unruptured intracranial aneurysm-repair (EUIAR). If INVB judges risk/success estimation similar for microsurgical/endovascular EUIAR, the choice for either modality is up to the informed patient. However, it is unknown if the patients' decision-making might be biased by the discipline of initial counselling prior to INVB and if INVB's equal risk/success estimation is finally accurate. METHODS We analysed all our patients with EUIAR after INVB-discussion between 2007 and 2017 and identified those patients where INVB-recommendation estimated similar risk/success rates for both treatment-modalities. We investigated the procedural/outcome parameters and determined if the mode of initial counselling prior to INVB influenced the patients' choice of EUIAR and if INVB's equal risk/success estimation was accurate. RESULTS Within altogether 572 patients with EUIAR during our study period, we identified 99 patients (agemean:58 yrs; m:f=1:2) in whom pre-treatment INVB-discussion estimated risk/success rates for both modalities of EUIAR to be similar. Prior to INVB-discussion, 80 of the 99 patients had been initially counselled in the neurosurgical discipline and 19 patients in the endovascular discipline. The final patients' decision rates for surgical vs. endovascular EUIAR (after secondary consultation of each patient in both disciplines after INVB-discussion) were 67% vs. 33% in the first and 58% vs. 42% in the latter group (no significant difference: p = 0.345). Uni- and multivariate analysis did not show any hints for a bias in patients' decision-making caused by the discipline of initial counselling prior to INVB/secondary bilateral consultations. Clinical and procedural outcome at last follow-up (median:18mos) did not differ between those 66 patients that eventually decided for microsurgical and those 33 patients that eventually decided for endovascular EUIAR, underlining the high accuracy of INVB's pre-treatment risk/success estimations. CONCLUSION Only in a small number of patients, INVB estimates both disciplines to be of equal value for EUIAR which proves to be highly accurate at long-term outcome measures. Initial contact to one or the other neurovascular discipline does not appear to play a significant role in the final patient's decision-making process.
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Affiliation(s)
- Sebastian Siller
- Neurosurgical Clinic, Clinic of the University of Munich (LMU), Campus Grosshadern, Marchioninistrasse 15, 81377 Munich, Germany; Department of Neuroradiology, Clinic of the University of Munich (LMU), Campus Grosshadern, Marchioninistrasse 15, 81377 Munich, Germany.
| | - Mathias Kunz
- Neurosurgical Clinic, Clinic of the University of Munich (LMU), Campus Grosshadern, Marchioninistrasse 15, 81377 Munich, Germany; Department of Neuroradiology, Clinic of the University of Munich (LMU), Campus Grosshadern, Marchioninistrasse 15, 81377 Munich, Germany
| | - Michael Lauseker
- Institute for Medical Information Processing, Biometry and Epidemiology, Clinic of the University of Munich (LMU), Campus Grosshadern, Marchioninistrasse 15, 81377 Munich, Germany; Department of Neuroradiology, Clinic of the University of Munich (LMU), Campus Grosshadern, Marchioninistrasse 15, 81377 Munich, Germany
| | - Konstantinos Dimitriadis
- Neurological Clinic, Clinic of the University of Munich (LMU), Campus Grosshadern, Marchioninistrasse 15, 81377 Munich, Germany; Department of Neuroradiology, Clinic of the University of Munich (LMU), Campus Grosshadern, Marchioninistrasse 15, 81377 Munich, Germany
| | - Franziska Dorn
- Institute for Medical Information Processing, Biometry and Epidemiology, Clinic of the University of Munich (LMU), Campus Grosshadern, Marchioninistrasse 15, 81377 Munich, Germany; Department of Neuroradiology, Clinic of the University of Munich (LMU), Campus Grosshadern, Marchioninistrasse 15, 81377 Munich, Germany; Department of Neuroradiology, University Hospital of Bonn, Venusberg Campus 1, 53127 Bonn, Germany
| | - Joerg-Christian Tonn
- Neurosurgical Clinic, Clinic of the University of Munich (LMU), Campus Grosshadern, Marchioninistrasse 15, 81377 Munich, Germany; Department of Neuroradiology, Clinic of the University of Munich (LMU), Campus Grosshadern, Marchioninistrasse 15, 81377 Munich, Germany
| | - Christian Schichor
- Neurosurgical Clinic, Clinic of the University of Munich (LMU), Campus Grosshadern, Marchioninistrasse 15, 81377 Munich, Germany; Department of Neuroradiology, Clinic of the University of Munich (LMU), Campus Grosshadern, Marchioninistrasse 15, 81377 Munich, Germany
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Jaramillo-Castell F, Lorenzo SM, Derqui DC, Murphy M, Aguilar CF, Nanwani K, Quintana-Díaz M, Martín-Martín JJ. Design, validation and piloting of clinical vignettes to analyze critical care clinical decision processes during the COVID-19 pandemic in three different countries (Spain, Chile and United States). RESEARCH SQUARE 2023:rs.3.rs-3208463. [PMID: 37609191 PMCID: PMC10441453 DOI: 10.21203/rs.3.rs-3208463/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
Background The use of heuristics in clinical decision-making processes increases in contexts of high uncertainty, such as those in Intensive Care Units (ICU. Given the impossibility of empirically studying their impact on real-world conditions, clinical vignettes were developed with the goal of identifying the use of heuristics in the care of critically ill patients during the COVID-19 pandemic in different clinical contexts. Methodology Vignettes were designed by critical care physicians in Spain to assess the use of representativeness, availability, and status quo heuristics in the care of critically ill patients during the COVID-19 pandemic. The construct, internal and external validity of the vignettes designed in Spain, the United States and Chile were evaluated. A questionnaire was piloted with the vignettes being validated in the three aforementioned countries through a computer application built for this purpose. Results 16 study vignettes grouped into 5 models were created: each model included between 2 and 4 vignettes. The vignettes designed were closed-response vignettes with 2-3 possible alternatives. The vignettes, initially developed in Spain in Spanish, were translated to English and adapted to the Spanish used in Chile. The clinical content of the vignettes was not modified during the translation process. Conclusions The vignettes allow for the study of the use of heuristics in critical care clinical decision making in the context of the COVID-19 pandemic. The piloting and validation process used can serve as a model for similar multinational studies exploring clinical decision making.
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Affiliation(s)
| | | | | | - Matthew Murphy
- Brown University Public Health Program: Brown University School of Public Health
| | | | - Kapil Nanwani
- La Paz University Hospital: Hospital Universitario La Paz
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Zheutlin AR, Niforatos JD, Chaitoff A. Equation-Based Low-Density Lipoprotein Cholesterol Reclassification and Implications For Lipid-Lowering Therapy. Mayo Clin Proc 2023; 98:1258-1259. [PMID: 37536811 DOI: 10.1016/j.mayocp.2023.06.001] [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: 02/16/2023] [Revised: 05/16/2023] [Accepted: 06/05/2023] [Indexed: 08/05/2023]
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Han D, Clarke-Deelder E, Miller N, Opondo K, Burke T, Oguttu M, McConnell M, Cohen J. Health care provider decision-making and the quality of maternity care: An analysis of postpartum care in Kenyan hospitals. Soc Sci Med 2023; 331:116071. [PMID: 37450989 PMCID: PMC10410252 DOI: 10.1016/j.socscimed.2023.116071] [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] [Received: 02/19/2023] [Revised: 05/17/2023] [Accepted: 07/02/2023] [Indexed: 07/18/2023]
Abstract
Evidence suggests that health care providers' non-adherence to clinical guidelines is widespread and contributes to poor patient outcomes across low- and middle-income countries. Through observations of maternity care in Kenya, we found limited adherence to guideline-recommended active monitoring of patients for signs of postpartum hemorrhage, the leading cause of maternal mortality, despite providers' having the necessary training and equipment. Using survey vignettes conducted with 144 maternity providers, we documented evidence consistent with subjective risk and perceived uncertainty driving providers' decisions to actively monitor patients. Motivated by these findings, we introduced a simple model of providers' decision-making about whether to monitor a patient, which may depend on their perceptions of risk, diagnostic uncertainty, and the value of new information. The model highlights key trade-offs between gathering diagnostic information through active monitoring versus waiting for signs and symptoms of hemorrhage to manifest. Our work provides a template for understanding provider decision-making and could inform interventions to encourage more proactive obstetric care.
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Affiliation(s)
- Dan Han
- Lee Kuan Yew School of Public Policy, National University of Singapore, Singapore; Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA, USA.
| | - Emma Clarke-Deelder
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA, USA; Department of Epidemiology and Public Health, Swiss TPH and University of Basel, Basel, Switzerland
| | - Nora Miller
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Kennedy Opondo
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA, USA; Kisumu Medical and Education Trust, Kisumu, Kenya
| | - Thomas Burke
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA, USA; Global Health Innovation Laboratory, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | | | - Margaret McConnell
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Jessica Cohen
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA, USA
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Davis J, Sanchez LD, Jarman AF, Macias-Konstantopoulos W, Newberry J, Patel S, Hess E, Burner E. 2022 consensus conference on diversity, equity, and inclusion: Developing an emergency medicine research agenda for addressing racism through health care research. Acad Emerg Med 2023; 30:731-741. [PMID: 37078910 PMCID: PMC10467350 DOI: 10.1111/acem.14742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 04/15/2023] [Accepted: 04/17/2023] [Indexed: 04/21/2023]
Abstract
Racism in emergency medicine (EM) health care research is pervasive but often underrecognized. To understand the current state of research on racism in EM health care research, we developed a consensus working group on this topic, which concluded a year of work with a consensus-building session as part of the overall Society for Academic Emergency Medicine (SAEM) consensus conference on diversity, equity, and inclusion: "Developing a Research Agenda for Addressing Racism in Emergency Medicine," held on May 10, 2022. In this article, we report the development, details of preconference methods and preliminary results, and the final consensus of the Healthcare Research Working Group. Preconference work based on literature review and expert opinion identified 13 potential priority research questions that were refined through an iterative process to a list of 10. During the conference, the subgroup used consensus methodology and a "consensus dollar" (contingent valuation) approach to prioritize research questions. The subgroup identified three research gaps: remedies for racial bias and systematic racism, biases and heuristics in clinical care, and racism in study design, and we derived a list of six high-priority research questions for our specialty.
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Affiliation(s)
- Joshua Davis
- University of Kansas School of Medicine, Wichita, Kansas, USA
| | - Leon D Sanchez
- Department of Emergency Medicine, Brigham and Women’s Faulkner Hospital, Boston, Massachusetts, USA
| | - Angela F Jarman
- Department of Emergency Medicine, University of California Davis, Sacramento, California, USA
| | | | - Jennifer Newberry
- Department of Emergency Medicine, Stanford University, Stanford, California, USA
| | - Shama Patel
- Department of Emergency Medicine University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Erik Hess
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Elizabeth Burner
- Department of Emergency Medicine, Kek School of Medicine of the University of Southern California, Los Angeles, California, USA
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Loftus TJ, Altieri MS, Balch JA, Abbott KL, Choi J, Marwaha JS, Hashimoto DA, Brat GA, Raftopoulos Y, Evans HL, Jackson GP, Walsh DS, Tignanelli CJ. Artificial Intelligence-enabled Decision Support in Surgery: State-of-the-art and Future Directions. Ann Surg 2023; 278:51-58. [PMID: 36942574 DOI: 10.1097/sla.0000000000005853] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
OBJECTIVE To summarize state-of-the-art artificial intelligence-enabled decision support in surgery and to quantify deficiencies in scientific rigor and reporting. BACKGROUND To positively affect surgical care, decision-support models must exceed current reporting guideline requirements by performing external and real-time validation, enrolling adequate sample sizes, reporting model precision, assessing performance across vulnerable populations, and achieving clinical implementation; the degree to which published models meet these criteria is unknown. METHODS Embase, PubMed, and MEDLINE databases were searched from their inception to September 21, 2022 for articles describing artificial intelligence-enabled decision support in surgery that uses preoperative or intraoperative data elements to predict complications within 90 days of surgery. Scientific rigor and reporting criteria were assessed and reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines. RESULTS Sample size ranged from 163-2,882,526, with 8/36 articles (22.2%) featuring sample sizes of less than 2000; 7 of these 8 articles (87.5%) had below-average (<0.83) area under the receiver operating characteristic or accuracy. Overall, 29 articles (80.6%) performed internal validation only, 5 (13.8%) performed external validation, and 2 (5.6%) performed real-time validation. Twenty-three articles (63.9%) reported precision. No articles reported performance across sociodemographic categories. Thirteen articles (36.1%) presented a framework that could be used for clinical implementation; none assessed clinical implementation efficacy. CONCLUSIONS Artificial intelligence-enabled decision support in surgery is limited by reliance on internal validation, small sample sizes that risk overfitting and sacrifice predictive performance, and failure to report confidence intervals, precision, equity analyses, and clinical implementation. Researchers should strive to improve scientific quality.
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Affiliation(s)
- Tyler J Loftus
- Department of Surgery, University of Florida Health, Gainesville, FL
- American College of Surgeons Health Information Technology Committee and Artificial Intelligence Subcommittee, Chicago, IL
| | - Maria S Altieri
- American College of Surgeons Health Information Technology Committee and Artificial Intelligence Subcommittee, Chicago, IL
- Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Jeremy A Balch
- Department of Surgery, University of Florida Health, Gainesville, FL
- American College of Surgeons Health Information Technology Committee and Artificial Intelligence Subcommittee, Chicago, IL
| | - Kenneth L Abbott
- Department of Surgery, University of Florida Health, Gainesville, FL
- American College of Surgeons Health Information Technology Committee and Artificial Intelligence Subcommittee, Chicago, IL
| | - Jeff Choi
- American College of Surgeons Health Information Technology Committee and Artificial Intelligence Subcommittee, Chicago, IL
- Department of Surgery, Stanford University, Stanford, CA
| | - Jayson S Marwaha
- American College of Surgeons Health Information Technology Committee and Artificial Intelligence Subcommittee, Chicago, IL
- Department of Surgery, Beth Israel Deaconess Medical Center
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA
| | - Daniel A Hashimoto
- American College of Surgeons Health Information Technology Committee and Artificial Intelligence Subcommittee, Chicago, IL
- Department of Surgery, University of Pennsylvania Perelman School of Medicine
- General Robotics, Automation, Sensing, and Perception Laboratory, University of Pennsylvania School of Engineering and Applied Science, Philadelphia, PA
| | - Gabriel A Brat
- American College of Surgeons Health Information Technology Committee and Artificial Intelligence Subcommittee, Chicago, IL
- Department of Surgery, Beth Israel Deaconess Medical Center
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA
| | - Yannis Raftopoulos
- American College of Surgeons Health Information Technology Committee and Artificial Intelligence Subcommittee, Chicago, IL
- Weight Management Program, Holyoke Medical Center, Holyoke, MA
| | - Heather L Evans
- American College of Surgeons Health Information Technology Committee and Artificial Intelligence Subcommittee, Chicago, IL
- Department of Surgery, Medical University of South Carolina, Charleston, SC
| | - Gretchen P Jackson
- American College of Surgeons Health Information Technology Committee and Artificial Intelligence Subcommittee, Chicago, IL
- Digital, Intuitive Surgical, Sunnyvale, CA; Departments of Pediatric Surgery, Pediatrics, and Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
| | - Danielle S Walsh
- American College of Surgeons Health Information Technology Committee and Artificial Intelligence Subcommittee, Chicago, IL
- Department of Surgery, University of Kentucky, Lexington, KY
| | - Christopher J Tignanelli
- American College of Surgeons Health Information Technology Committee and Artificial Intelligence Subcommittee, Chicago, IL
- Department of Surgery
- Institute for Health Informatics
- Program for Clinical Artificial Intelligence, Center for Learning Health Systems Science, University of Minnesota, Minneapolis, MN
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