Omission Bias and Decision Making in Pulmonary and Critical Care Medicine

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

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

Time-Limited Trials for Patients With Critical Illness: A Review of the Literature

TOPIC IMPORTANCE

Since the 1990s, time-limited trials have been described as an approach to navigate uncertain benefits and limits of life-sustaining therapies in patients with critical illness. In this review, we aim to synthesize the evidence on time-limited trials in critical care, establish what is known, and highlight important knowledge gaps.

REVIEW FINDINGS

We identified 18 empirical studies and 15 ethical analyses about time-limited trials in patients with critical illness. Observational studies suggest time-limited trials are part of current practice in ICUs in the United States, but their use varies according to unit and physician factors. Some ICU physicians are familiar with, endorse, and have participated in time-limited trials, and some older adults appear to favor time-limited trial strategies over indefinite life-sustaining therapy or care immediately focused on comfort. When time-limited trials are used, they are often implemented incompletely and challenged by systematic barriers (eg, continually rotating ICU staff). Predictive modeling studies support prevailing clinical wisdom that prognostic uncertainty decreases over time in the ICU for some patients. One study prospectively comparing usual ICU care with an intervention designed to support time-limited trials yielded promising preliminary results. Ethical analyses describe time-limited trials as a pragmatic approach within the longstanding discussion about withholding and withdrawing life-sustaining therapies.

SUMMARY

Time-limited trials are endorsed by physicians, align with the priorities of some older adults, and are part of current practice. Substantial efforts are needed to test their impact on patient-centered outcomes, improve their implementation, and maximize their potential benefit.

Cognitive bias during clinical decision-making and its influence on patient outcomes in the emergency department: A scoping review

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.

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)

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.

Cognitive biases in internal medicine: a scoping review

BACKGROUND

Medical errors account for up to 440,000 deaths annually, and cognitive errors outpace knowledge deficits as causes of error. Cognitive biases are predispositions to respond in predictable ways, and they don't always result in error. We conducted a scoping review exploring which biases are most prevalent in Internal Medicine (IM), if and how they influence patient outcomes, and what, if any, debiasing strategies are effective.

CONTENT

We searched PubMed, OVID, ERIC, SCOPUS, PsychINFO, and CINAHL. Search terms included variations of "bias", "clinical reasoning", and IM subspecialties. Inclusion criteria were: discussing bias, clinical reasoning, and physician participants.

SUMMARY

Fifteen of 334 identified papers were included. Two papers looked beyond general IM: one each in Infectious Diseases and Critical Care. Nine papers distinguished bias from error, whereas four referenced error in their definition of bias. The most commonly studied outcomes were diagnosis, treatment, and physician impact in 47 % (7), 33 % (5), and 27 % (4) of studies, respectively. Three studies directly assessed patient outcomes. The most commonly cited biases were availability bias (60 %, 9), confirmation bias (40 %, 6), anchoring (40 %, 6), and premature closure (33 %, 5). Proposed contributing features were years of practice, stressors, and practice setting. One study found that years of practice negatively correlated with susceptibility to bias. Ten studies discussed debiasing; all reported weak or equivocal efficacy.

OUTLOOK

We found 41 biases in IM and 22 features that may predispose physicians to bias. We found little evidence directly linking biases to error, which could account for the weak evidence of bias countermeasure efficacy. Future study clearly delineating bias from error and directly assessing clinical outcomes would be insightful.

Context Matters: Emotional Sensitivity to Probabilities and the Bias for Action in Cancer Treatment Decisions

BACKGROUND

Past studies have shown a commission bias for cancer treatment, a tendency to choose active treatment even when watchful waiting is less risky. This bias suggests motivations for action beyond mortality statistics, but recent evidence suggests that individuals differ in their emotional sensitivity to probabilities (ESP), the tendency to calibrate emotional reactions to probability. The current study aims to examine the role of ESP in the commission bias, specifically whether those higher in ESP are more likely to choose watchful waiting when risk probabilities align with that choice.

METHODS

Participants (N = 1,055) read a scenario describing a hypothetical cancer diagnosis and chose between surgery and watchful waiting, with random assignment between versions where the mortality rate was either lower for surgery or for watchful waiting. We modeled choice using the Possibility Probability Questionnaire (PPQ), a measure of ESP, and several other individual differences in a logistic regression.

RESULTS

We observed a commission bias as in past studies with most participants choosing surgery both when surgery was optimal (71%) and when watchful waiting was optimal (58%). An ESP × Condition interaction indicated that the predictive role of ESP depended on condition. Those higher in ESP were more likely to choose surgery when probabilities favored surgery, β = 0.57, P < 0.001, but when probabilities favored watchful waiting, ESP had a near-zero relationship with choice, β = 0.05, P < 0.99.

CONCLUSIONS

The role of ESP in decision making is context specific. Higher levels of ESP predict choosing action when that action is warranted but do not predict a shift away from surgery when watchful waiting offers better chances of survival. ESP does not overcome the commission bias.

HIGHLIGHTS

Past studies have identified a "commission bias," a tendency to choose active treatment over watchful waiting, even when mortality rate is lower for waiting.Evaluation of risk probabilities is related to individual differences in emotional sensitivity to probabilities (ESP) and has been shown to predict reactions to and decisions about health risk situations.ESP appears to be selectively factored into decision making. ESP was a robust predictor of choosing surgery when probability information supported surgery but did not predict decisions when probability information supported watchful waiting.Those who are most emotionally attuned to probabilities are just as susceptible to the commission bias as those who are less attuned.

Headache neuroimaging: A survey of current practice, barriers, and facilitators to optimal use

OBJECTIVE

The objective of this study was to understand current practice, clinician understanding, attitudes, barriers, and facilitators to optimal headache neuroimaging practices.

BACKGROUND

Headaches are common in adults, and neuroimaging for these patients is common, costly, and increasing. Although guidelines recommend against routine headache neuroimaging in low-risk scenarios, guideline-discordant neuroimaging is still frequently performed.

METHODS

We administered a 60-item survey to headache clinicians at the Veterans Affairs health system to assess clinician understanding and attitudes on headache neuroimaging and to determine neuroimaging practice patterns for three scenarios describing hypothetical patients with headaches. Descriptive statistics were used to summarize responses, stratified by clinician type (physicians or advanced practice clinicians [APCs]) and specialty (neurology or primary care).

RESULTS

The survey was successfully completed by 431 of 1426 clinicians (30.2% response rate). Overall, 317 of 429 (73.9%) believed neuroimaging was overused for patients with headaches. However, clinicians would utilize neuroimaging a mean (SD) 30.9% (31.7) of the time in a low-risk scenario without red flags, and a mean 67.1% (31.9) of the time in the presence of minor red flags. Clinicians had stronger beliefs in the potential benefits (268/429, 62.5%) of neuroimaging compared to harms (181/429, 42.2%) and more clinicians were bothered by harms stemming from the omission of neuroimaging (377/426, 88.5%) compared to commission (329/424, 77.6%). Additionally, APCs utilized neuroimaging more frequently than physicians and were more receptive to potential interventions to improve neuroimaging utilization.

CONCLUSIONS

Although a majority of clinicians believed neuroimaging was overused for patients with headaches, many would utilize neuroimaging in low-risk scenarios with a small probability of changing management. Future studies are needed to define the role of currently used red flags given their importance in neuroimaging decisions. Importantly, APCs may be an ideal target for future optimization efforts.

Impact of nonclinical factors on intensive care unit admission decisions: a vignette-based randomized trial (V-TRIAGE)

OBJECTIVE

To assess the impact of intensive care unit bed availability, distractors and choice framing on intensive care unit admission decisions.

METHODS

This study was a randomized factorial trial using patient-based vignettes. The vignettes were deemed archetypical for intensive care unit admission or refusal, as judged by a group of experts. Intensive care unit physicians were randomized to 1) an increased distraction (intervention) or a control group, 2) an intensive care unit bed scarcity or nonscarcity (availability) setting, and 3) a multiple-choice or omission (status quo) vignette scenario. The primary outcome was the proportion of appropriate intensive care unit allocations, defined as concordance with the allocation decision made by the group of experts.

RESULTS

We analyzed 125 physicians. Overall, distractors had no impact on the outcome; however, there was a differential drop-out rate, with fewer physicians in the intervention arm completing the questionnaire. Intensive care unit bed availability was associated with an inappropriate allocation of vignettes deemed inappropriate for intensive care unit admission (OR = 2.47; 95%CI 1.19 - 5.11) but not of vignettes appropriate for intensive care unit admission. There was a significant interaction with the presence of distractors (p = 0.007), with intensive care unit bed availability being associated with increased intensive care unit admission of vignettes inappropriate for intensive care unit admission in the distractor (intervention) arm (OR = 9.82; 95%CI 2.68 - 25.93) but not in the control group (OR = 1.02; 95%CI 0.38 - 2.72). Multiple choices were associated with increased inappropriate allocation in comparison to the omission group (OR = 5.18; 95%CI 1.37 - 19.61).

CONCLUSION

Intensive care unit bed availability and cognitive biases were associated with inappropriate intensive care unit allocation decisions. These findings may have implications for intensive care unit admission policies.

Cognitive biases, environmental, patient and personal factors associated with critical care decision making: A scoping review

PURPOSE

Cognitive biases and factors affecting decision making in critical care can potentially lead to life-threatening errors. We aimed to examine the existing evidence on the influence of cognitive biases and factors on decision making in critical care.

MATERIALS AND METHODS

We conducted a scoping review by searching MEDLINE for articles from 2004 to November 2020. We included studies conducted in physicians that described cognitive biases or factors associated with decision making. During the study process we decided on the method to summarize the evidence, and based on the obtained studies a descriptive summary of findings was the best fit.

RESULTS

Thirty heterogenous studies were included. Four main biases or factors were observed, e.g. cognitive biases, personal factors, environmental factors, and patient factors. Six (20%) studies reported biases associated with decision making comprising omission-, status quo-, implicit-, explicit-, outcome-, and overconfidence bias. Nineteen (63%) studies described personal factors, twenty-two (73%) studies described environmental factors, and sixteen (53%) studies described patient factors.

CONCLUSIONS

The current evidence on cognitive biases and factors is heterogenous, but shows they influence clinical decision. Future studies should investigate the prevalence of cognitive biases and factors in clinical practice and their impact on clinical outcomes.

Investigation of pulmonary embolism in patients with chest pain in the emergency department: a retrospective multicenter study

INTRODUCTION

Chest pain is a common main complaint in the emergency department. Among its associated differential diagnoses, pulmonary embolism remains a key concern for the clinician. There are no clear recommendations on which patients should have a formal workup for pulmonary embolism diagnosis. The objective of this study was to determine the proportion of patients with chest pain who were investigated for pulmonary embolism diagnosis and to determine the clinical profile of these patients.

METHODS

This was a retrospective multicenter study conducted in three French Emergency Departments. We included all patients who presented to these centers for chest pain during a 2-month period. The primary outcome was the initiation of pulmonary embolism workup. We also aimed to find factors associated with this outcome.

RESULTS

We included 881 patients with a main complaint of chest pain. Mean age was 50 years and 481 (56%) were men. A total of 263 patients (30%, 95% confidence interval 27-33%) had a formal pulmonary embolism workup, and pulmonary embolism was ultimately diagnosed in 7 cases (prevalence of 2.6%, 95% confidence interval 1.1-5.3%). Five factors were identified as independently associated with a workup for pulmonary embolism diagnosis: female sex, young age, no ischemic heart disease, recent flight and associated dyspnea.

CONCLUSION

Among patients presenting to emergency department with chest pain, 30% had a workup for pulmonary embolism. We report five clinical variables independently associated with a higher probability of pulmonary embolism workup in our sample.

A conceptual model of barriers and facilitators to primary clinical teams requesting pediatric palliative care consultation based upon a narrative review

BACKGROUND

Despite evidence that referral to pediatric palliative care reduces suffering and improves quality of life for patients and families, many clinicians delay referral until the end of life. The purpose of this article is to provide a conceptual model for why clinical teams delay discussing palliative care with parents.

DISCUSSION

Building on a prior model of parent regoaling and relevant research literature, we argue for a conceptual model of the challenges and facilitators a clinical team might face in shifting from a restorative-focused treatment plan to a plan that includes palliative aspects, resulting in a subspecialty palliative care referral. Like patients and families, clinicians and clinical teams may recognize that a seriously ill patient would benefit from palliative care and shift from a restorative mindset to a palliative approach. We call this transition "clinician regoaling". Clinicians may experience inhibitors and facilitators to this transition at both the individual and team level which influence the clinicians' willingness to consult subspecialty palliative care. The 8 inhibitors to team level regoaling include: 1) team challenges due to hierarchy, 2) avoidance of criticizing colleagues, 3) structural communication challenges, 4) group norms in favor of restorative goals, 5) diffusion of responsibility, 6) inhibited expression of sorrow, 7) lack of social support, 8) reinforcement of labeling and conflict. The 6 facilitators of team regoaling include: 1) processes to build a shared mental model, 2) mutual trust to encourage dissent, 3) anticipating conflict and team problem solving, 4) processes for reevaluation of goals, 5) sharing serious news as a team, 6) team flexibility.

CONCLUSIONS

Recognizing potential team level inhibitors to transitioning to palliative care can help clinicians develop strategies for making the transition more effectively when appropriate.

The perceived severity of a disease and the impact of the vocabulary used to convey information: using Rasch scaling in a simulated oncological scenario

BACKGROUND

Healthcare staff should be aware of the importance that patients may attach to the words that are used to convey information. This is relevant in terms of the patients' understanding. Modeling how people understand the information conveyed in a medical context may help health practitioners to better appreciate the patients' approach.

PURPOSE

1) Analyze the participants' self-reported perception of the type of information provided in an oncological scenario in terms of three dimensions: impairment to their health, risks associated with the disease itself and commitment required to undergo the treatment; and 2) show the benefits of using Rasch scaling for the analysis of the data. Starting from a survey, Rasch scaling produces a unidimensional logit-interval scale relating to the extent to which each item conveys a latent dimension. These were related to structure, in particular concerning communication by means of opposite vs. unipolar language.

SUBJECTS AND METHODS

The participants rated 82 items of information in a questionnaire regarding their perception of impairment to their health (H) and the risks (R) and commitment relating to the treatment prescribed (T).

RESULTS

The scaling produced an item bank for healthcare staff to consult in order to estimate the importance the recipient would be likely to attach to the vocabulary used and the likely impact of the information in terms of the patient's condition. Furthermore, the use of opposites was generally associated with a clearer impression of whether the information given was generally only very negative or slightly negative, whereas 'neutral' information was often perceived as being very negative.

ACTUAL FINDINGS

Is possible to estimate people's understanding more precisely (in terms of H, R and T) which can help healthcare practitioners to modulate the way they convey information.

LIMITATIONS

The participants in the study were healthy volunteers and the context was simulated.

Physicians' perspectives on communication and decision making in clinical encounters for treatment of latent tuberculosis infection

The aim of the study was to explore the views of tuberculosis (TB) physicians on treatment of latent TB infection (LTBI), focusing on decision making and communication in clinical practice.

20 Australian TB physicians participated in a semistructured interview in person or over the telephone. Interviews were recorded, transcribed and analysed thematically.

The study identified challenges that physicians face when discussing treatment for LTBI with patients. These included difficulties explaining the concept of latency (in particular to patients from culturally and linguistically diverse backgrounds) and providing guidance to patients while still framing treatment decisions as a choice. Tailored estimates of the risk of developing TB and the risk of developing an adverse effect from LTBI treatment were considered the most important information for decision making and discussion with patients. Physicians acknowledged that there is a significant amount of unwarranted treatment variation, which they attributed to the lack of evidence about the risk–benefit balance of LTBI treatment in certain scenarios and guidelines that refer to the need for case-by-case decision making in many instances.

In order to successfully implement LTBI treatment at a clinical level, consideration should be given to research on how to best address communication challenges arising in clinical encounters.

Overcoming challenges in clinical encounters is essential for implementation of treatment of latent TB infectionhttp://ow.ly/HEFu30izBUu

[Systematic errors in clinical studies : A comprehensive survey]

Systematic errors and related phenomena represent an intrinsic challenge to the quality of clinical research. As a consequence even otherwise methodologically demanding studies may produce results that systematically differ from the true values. Systematic errors relating to investigative medicine are divided into six groups according to their affiliation with the consecutive chronological sections of the study. Bias can occur in preliminary literature research in the field, specifying the study design and selecting the study sample, measuring exposure and outcome, analyzing the data, interpreting the analyses and publishing the results. The most important systematic errors that concern diagnostic and interventional studies are created by access to the data of previous tests, calculated study design, preselection of the participants, comparison with non-contemporaneous controls, antedating the time of diagnosis and overdiagnosis of slowly progressive forms of diseases examined. Checking the measured values often leads to a mosaic of several biases with one being more or less dominant. Even by exercising due care in the preparation and performance of the study, the majority of distortions cannot be eliminated but only diminished. It is essential to consider each detected bias as a potential full or partial argument in support of an observed correlation. The control of systematic errors and related phenomena is both a significant element of the discussion of the study report and a key element for assessment of its scientific value.

[Systematic errors in clinical studies : A comprehensive survey]

Systematic errors and related phenomena represent an intrinsic challenge to the quality of clinical research. As a consequence even otherwise methodologically demanding studies may produce results that systematically differ from the true values. Systematic errors relating to investigative medicine are divided into six groups according to their affiliation with the consecutive chronological sections of the study. Bias can occur in preliminary literature research in the field, specifying the study design and selecting the study sample, measuring exposure and outcome, analyzing the data, interpreting the analyses and publishing the results. The most important systematic errors that concern diagnostic and interventional studies are created by access to the data of previous tests, calculated study design, preselection of the participants, comparison with non-contemporaneous controls, antedating the time of diagnosis and overdiagnosis of slowly progressive forms of diseases examined. Checking the measured values often leads to a mosaic of several biases with one being more or less dominant. Even by exercising due care in the preparation and performance of the study, the majority of distortions cannot be eliminated but only diminished. It is essential to consider each detected bias as a potential full or partial argument in support of an observed correlation. The control of systematic errors and related phenomena is both a significant element of the discussion of the study report and a key element for assessment of its scientific value.

Development of an algorithm to aid triage decisions for intensive care unit admission: a clinical vignette and retrospective cohort study

BACKGROUND

Intensive care unit (ICU) admission triage is performed routinely and is often based solely on clinical judgment, which could mask biases. A computerized algorithm to aid ICU triage decisions was developed to classify patients into the Society of Critical Care Medicine's prioritization system. In this study, we sought to evaluate the reliability and validity of this algorithm.

METHODS

Nine senior physicians evaluated forty clinical vignettes based on real patients. The reference standard was defined as the priorities ascribed by two investigators with full access to patients' records. Agreement of algorithm-based priorities with the reference standard and with intuitive priorities provided by the physicians were evaluated. Correlations between algorithm prioritization and physicians' judgment of the appropriateness of ICU admissions in scarcity and nonscarcity settings were also evaluated. Validity was further assessed by retrospectively applying this algorithm to 603 patients with requests for ICU admission for association with clinical outcomes.

RESULTS

Agreement between algorithm-based priorities and the reference standard was substantial, with a median κ of 0.72 (interquartile range [IQR] 0.52-0.77). Algorithm-based priorities demonstrated higher interrater reliability (overall κ 0.61, 95% confidence interval [CI] 0.57-0.65; median percentage agreement 0.64, IQR 0.59-0.70) than physicians' intuitive prioritization (overall κ 0.51, 95% CI 0.47-0.55; median percentage agreement 0.49, IQR 0.44-0.56) (p = 0.001). Algorithm-based priorities were also associated with physicians' judgment of appropriateness of ICU admission (priorities 1, 2, 3, and 4 vignettes would be admitted to the last ICU bed in 83.7%, 61.2%, 45.2%, and 16.8% of the scenarios, respectively; p < 0.001) and with actual ICU admission, palliative care consultation, and hospital mortality in the retrospective cohort.

CONCLUSIONS

This ICU admission triage algorithm demonstrated good reliability and validity. However, more studies are needed to evaluate a difference in benefit of ICU admission justifying the admission of one priority stratum over the others.

Understanding Decision Making in Critical Care

BACKGROUND

Human decision making involves the deliberate formulation of hypotheses and plans as well as the use of subconscious means of judging probability, likely outcome, and proper action.

RATIONALE

There is a growing recognition that intuitive strategies such as use of heuristics and pattern recognition described in other industries are applicable to high-acuity environments in medicine. Despite the applicability of theories of cognition to the intensive care unit, a discussion of decision-making strategies is currently absent in the critical care literature.

CONTENT

This article provides an overview of known cognitive strategies, as well as a synthesis of their use in critical care. By understanding the ways by which humans formulate diagnoses and make critical decisions, we may be able to minimize errors in our own judgments as well as build training activities around known strengths and limitations of cognition.

Neurosurgical decision making: personal and professional preferences

OBJECT

Physicians are often solicited by patients or colleagues for clinical recommendations they would make for themselves if faced by a clinical situation. The act of making a recommendation can alter the clinical course being taken. The authors sought to understand this dynamic across different neurosurgical scenarios by examining how neurosurgeons value the procedures that they offer.

METHODS

The authors conducted an online survey using the Congress of Neurological Surgeons listserv in May 2013. Respondents were randomized to answer either as the surgeon or as the patient. Questions encompassed an array of distinct neurosurgical scenarios. Data on practice parameters and experience levels were also collected.

RESULTS

Of the 534 survey responses, 279 responded as the “neurosurgeon” and 255 as the “patient.” For both vestibular schwannoma and arteriovenous malformation management, more respondents chose resection for their patient but radiosurgery for themselves (p = 0.002 and p = 0.001, respectively). Aneurysm coiling was chosen more often than clipping, but those whose practice was ≥ 30% open cerebrovascular neurosurgery were less likely to choose coiling. Overall, neurosurgeons who focus predominantly on tumors were more aggressive in managing the glioma, vestibular schwannoma, arteriovenous malformation, and trauma. Neurosurgeons more than 10 years out of residency were less likely to recommend surgery for management of spinal pain, aneurysm, arteriovenous malformation, and trauma scenarios.

CONCLUSIONS

In the majority of cases, altering the role of the surgeon did not change the decision to pursue treatment. In certain clinical scenarios, however, neurosurgeons chose treatment options for themselves that were different from what they would have chosen for (or recommended to) their patients. For the management of vestibular schwannomas, arteriovenous malformations, intracranial aneurysms, and hypertensive hemorrhages, responses favored less invasive interventions when the surgeon was the patient. These findings are likely a result of cognitive biases, previous training, experience, areas of expertise, and personal values.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

The twin traps of overtreatment and therapeutic nihilism in clinical practice

CONTEXT

The modern version of the Hippocratic Oath requires doctors to swear that they will apply, for the benefit of the sick, all measures that are required, avoiding the twin traps of overtreatment and therapeutic nihilism. This paper explores the magnitude of the problem of overtreatment and undertreatment and the potential sources of these treatment errors.

METHODS

We undertook a narrative review of the literature on errors in treatment associated with flaws in doctors' judgements and present evidence from research into clinical reasoning and from psychological research into decision making. Based on evidence from these two research fields, we explored the possible reasons why doctors erroneously withhold or unnecessarily administer treatments.

RESULTS

Variation in treatment has been documented, even with similar clinical presentations under a variety of conditions, suggesting that overtreatment and undertreatment actually occur, with adverse effects for patients. Both types of error have been demonstrated, even when the doctor arrived at the correct diagnosis. They may be associated with the influence exerted on doctors' treatment judgements by factors that are unrelated to the specific problem, such as patients' socio-demographic characteristics and the doctor's practice culture. Doctors are also subject to commission bias and to omission bias, which have been demonstrated to occur in several domains. Such biases lead doctors to administer unnecessary treatments or to withhold required treatments due to anticipated regret. Little is known about cognitive processes underlying doctors' treatment decisions, but mental representations of diseases that provide the basis for diagnostic reasoning are also probably used for treatment judgements.

CONCLUSIONS

Doctors are at risk of falling into the twin traps of overtreatment and therapeutic nihilism. Further research should explore how to avoid these traps, but it may require deliberate reflection on problems to be solved to counteract the influence of factors that are beyond the patient's problem.

Cognitive Processes in Anesthesiology Decision Making

The quality and safety of health care are under increasing scrutiny. Recent studies suggest that medical errors, practice variability, and guideline noncompliance are common, and that cognitive error contributes significantly to delayed or incorrect diagnoses. These observations have increased interest in understanding decision-making psychology.

Many nonrational (i.e., not purely based in statistics) cognitive factors influence medical decisions and may lead to error. The most well-studied include heuristics, preferences for certainty, overconfidence, affective (emotional) influences, memory distortions, bias, and social forces such as fairness or blame.

Although the extent to which such cognitive processes play a role in anesthesia practice is unknown, anesthesia care frequently requires rapid, complex decisions that are most susceptible to decision errors. This review will examine current theories of human decision behavior, identify effects of nonrational cognitive processes on decision making, describe characteristic anesthesia decisions in this context, and suggest strategies to improve decision making.

Better Medicine by Default

Background. American health care is transitioning to electronic physician ordering. These computerized systems are unique because they allow custom order interfaces. Although these systems provide great benefits, there are also potential pitfalls, as the behavioral sciences have shown that the very format of electronic interfaces can influence decision making. The current research specifically examines how defaults in electronic order templates affect physicians’ treatment decisions and medical errors. Methods. Forty-five medical residents completed order sets for 3 medical case studies. Participants were randomly assigned to receive order sets with either “opt-in” defaults (options visible but unselected) or “opt-out” defaults (options visible and preselected). Results compare error rates between conditions and examine the type and severity of errors most often made with opt-in versus opt-out defaults. Results. Opt-out defaults resulted in a greater number of items ordered and specifically increased commission errors (overordering) compared with opt-in defaults. However, while opt-in defaults resulted in fewer orders, they also increased omission errors. When the severity of the errors is taken into account, the default effects seem limited to less severe errors. Conclusion. The defaults used in electronic order sets influence medical treatment decisions when the consequences to a patient’s health are low. This pattern suggests that physicians cognitively override incorrect default choices but only to a point, and it implies tradeoffs that maximize accuracy and minimize cognitive effort. Results indicate that defaults for low-impact items on electronic templates warrant careful attention because physicians are unlikely to override them.

A systematic review of tools for predicting severe adverse events following patient discharge from intensive care units

Introduction

The discharge of patients from the intensive care unit (ICU) to a hospital ward is a common transition of care that is associated with error and adverse events. Risk stratification tools may help identify high-risk patients for targeted interventions, but it is unclear if proper tools have been developed.

Methods

We searched Ovid EMBASE, Ovid MEDLINE, CINAHL, PUBMED and Cochrane Central Register of Controlled Trials from the earliest available date through March 2013, plus reference lists and citations of all studies included in the systematic review. Cohort studies were selected that described the derivation, validation or clinical impact of tools for predicting medical emergency team activation, ICU readmission or mortality following patient discharge from the ICU. Data were extracted on the study design, setting, population, sample size, tool (components, measurement properties) and outcomes.

Results

The literature search identified 9,926 citations, of which eight studies describing eight tools met the inclusion criteria. Reported outcomes included ICU readmission (n = 4 studies), hospital mortality (n = 3 studies) and both ICU readmission and hospital mortality (n = 1 studies). Seven of the tools were comprised of distinct measurable component variables, while one tool used subjective scoring of patient risk by intensive care physicians. The areas under receiver operator curves were reported for all studies and ranged from 0.66 to 0.92. A single study provided a direct comparative analysis between two tools. We did not find any studies evaluating the impact of risk prediction on processes and outcomes of care.

Conclusions

Eight risk stratification tools for predicting severe adverse events following patient discharge from ICU have been developed, but have undergone limited comparative evaluation. Although risk stratification tools may help clinician decision-making, further evaluation of the existing tools' effects on care is required prior to clinical implementation.

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

Despite the current push toward the practice of evidence-based medicine and comparative effectiveness research, clinicians' decisions may be influenced not only by evidence, but also by cognitive biases. A cognitive bias describes a tendency to make systematic errors in certain circumstances based on cognitive factors rather than evidence. Though health care providers have been shown in several studies to be susceptible to a variety of types of cognitive biases, research on the role of the sunk-cost bias in clinical decision-making is extremely limited. The sunk-cost bias is the tendency to pursue a course of action, even after it has proved to be suboptimal, because resources have been invested in that course of action. This study explores whether health care providers' medical treatment recommendations are affected by prior investments in a course of treatment. Specifically, we surveyed 389 health care providers in a large urban medical center in the United States during August 2009. We asked participants to make a treatment recommendation based on one of four hypothetical clinical scenarios that varied in the source and type of prior investment described. By comparing recommendations across scenarios, we found that providers did not demonstrate a sunk-cost effect; rather, they demonstrated a significant tendency to over-compensate for the effect. In addition, we found that more than one in ten health care providers recommended continuation of an ineffective treatment.

Why surgeons can say "no": exploring "unilateral withholding"

OBJECTIVE

To explore why it is permissible for surgeons to "unilaterally withhold" surgery, whereas it is not commonplace (in the United States) to unilaterally withhold cardiopulmonary resuscitation (CPR) for clinical situations with similar degrees of uncertainty and prognosis.

DATA SOURCES

The medical literature was sampled using PubMed and Google search engines, employing a variety of search strategies to capture articles relating to medical/surgical decision-making, risk aversion, acute care surgery, and withholding life-saving therapies. These topics are used to highlight interprovider variability that affects all practitioners-not just surgeons-and to consider why we deem it permissible for surgeons to withhold surgery, whereas-in the United States, at least-it is not routinely permissible for clinicians to unilaterally withhold mechanical ventilation and CPR for cases with similar prognoses.

CONCLUSIONS

While there are no published research studies that deal directly with this topic, knowledge, heuristics, experience, variable aversion to risk, and other features inherent in medical-surgical education likely impact decisions to offer or withhold potentially life-saving therapies of all kinds. Both surgeons and clinicians, who request surgical consultation for hospitalized patients, should consider these issues and politely pursue second opinions when there is any doubt whether forgoing surgery is in the patient's best interests. Similarly, while unilateral withholding of CPR is not commonly employed in some medical cultures, including the United States, beneficence can be facilitated through robust informed consent.

Reasons for non-use of proven pharmacotherapeutic interventions: systematic review and framework development

RATIONALE, AIMS AND OBJECTIVES

The quality of patient care and safety is dependent on addressing both errors of commission (e.g. overuse of medications) and errors of omission (e.g. patients receiving too little care). Despite guidelines recommending the use of certain proven pharmacotherapeutic interventions, a large gap exists between the patients that have an indication for, and those that actually receive such interventions. To address how the rate of implementation of proven interventions can be improved is dependent on a comprehensive knowledge of the factors contributing to their underuse. The aim of the review is to create an evidence-based framework of reasons why eligible patients do not receive proven pharmacotherapeutic interventions.

METHODS

A systemic review of the published reasons for non-use based on the Cochrane methodology.

RESULTS

The systematic review identified 67 articles meeting the inclusion criteria. The reasons for non-use were extracted from the studies and a framework was created from the results.

CONCLUSIONS

The factors associated with lack of implementation of proven pharmacotherapeutic interventions are complex and heterogeneous but can be understood from the perspectives of clinicians, patients and health care delivery systems. Efforts to increase the utilization of proven interventions should focus on disease/intervention-specific programmes that take into account the identified modifiable clinician, patient and system factors.

Ethics and hypothermia treatment

Hypothermia is the first effective neuroprotective intervention for newborns who are critically ill following a life-threatening asphyxial insult. It is not surprising that it has raised complex and controversial ethical dilemmas for investigators and clinicians. Given the history of iatrogenic disasters in neonatology, there has been an understandable reluctance to incorporate hypothermia into routine clinical practice until there is persuasive evidence from high quality randomised trials. This article reviews ethical issues that arose during the design of the original clinical trials, the implications of accumulating evidence of safety and efficacy, and the problems of ensuring informed parental participation in treatment decisions.

An investigation of dentists' and dental students' estimates of diagnostic probabilities

BACKGROUND

Research in medicine has shown that physicians have difficulty estimating the probability that a patient has a condition on the basis of available diagnostic evidence. They consistently undervalue baseline information about the patient relative to test information and are poor intuitive calculators of probability. The authors could not locate in the literature any studies of diagnostic probability estimates from baseline information and test data for dentists.

METHODS

Using two vignettes that contained different baseline information, dental students and clinical faculty members estimated the probability that the described hypothetical patient had the condition in question. Respondents also commented on the project.

CONCLUSIONS

Both groups of respondents overemphasized the importance of test evidence relative to baseline information, although experienced practitioners did so to a lesser extent than did students. Respondents, especially practitioners, expressed resistance to performing a diagnostic task that required precise estimates of probability.

CLINICAL IMPLICATIONS

Dentists appear to estimate diagnostic probabilities in an intuitive fashion, but they do so imprecisely. Clinical experience provides some protection against the bias of overestimating test evidence compared with baseline information. These findings raise questions about how practitioners use probability estimates and whether other models also may play a role. The incorporation of information from evidence-based dentistry into practice requires better understanding.

What Makes a Tumor Diagnosis a Call to Action? On the Preference for Action versus Inaction

Background. Many studies have shown an omission bias, but when the context is cancer, people seem to prefer active treatments to watchful waiting. Objective. First, to investigate whether the preference for active treatment for cancer could depend on the associations attached to the inaction option, and second, to explore the kind of diagnosis that gives rise to the preference for action, by comparing scenarios differing in the status of the illness (already present v. could arise in the future), the kind of diagnosis (malign tumor, benign tumor, or nontumor), and the possible development of the tumor (growth v. degeneration). Design. Between-subjects design with 8 hypothetical scenarios. Participants. A total of 735 students participated in an Internet survey. Measurements. Choice between watchful waiting and surgery, perceived severity of the diagnosis. Results. Active treatment was preferred only when the scenario described watchful waiting as excluding surgery in the future. The critical aspect for participants’ preference for active treatment was the malignancy of the tumor currently diagnosed. Perceived severity was also a significant predictor of treatment choice. Limitations. Inability to infer causation in the relationship between choice and perceived severity. Conclusions. Action is preferred to inaction when a malignant tumor is currently diagnosed and active treatments are not allowed in the future; under other conditions, participants prefer inaction (e.g., when active treatments are allowed in the future, or when the tumor is benign) or exhibit no preference (e.g., when it is not specified whether active treatments are allowed in the future).

A simple clinical predictive index for objective estimates of mortality in acute lung injury

OBJECTIVE

We sought to develop a simple point score that would accurately capture the risk of hospital death for patients with acute lung injury (ALI).

DESIGN

This is a secondary analysis of data from two randomized trials. Baseline clinical variables collected within 24 hours of enrollment were modeled as predictors of hospital mortality using logistic regression and bootstrap resampling to arrive at a parsimonious model. We constructed a point score based on regression coefficients.

SETTING

Medical centers participating in the Acute Respiratory Distress Syndrome Clinical Trials Network (ARDSnet).

PATIENTS

Model development: 414 patients with nontraumatic ALI participating in the low tidal volume arm of the ARDSnet Acute Respiratory Management in ARDS study. Model validation: 459 patients participating in the ARDSnet Assessment of Low tidal Volume and elevated End-expiratory volume to Obviate Lung Injury study. Model Validation: 459 patients participating in the ARDSnet Assessment of Low tidal Volume and elevated End-expiratory volume to Obviate Lung Injury trial.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Variables comprising the prognostic model were hematocrit <26% (1 point), bilirubin >or=2 mg/dL (1 point), fluid balance >2.5 L positive (1 point), and age (1 point for age 40-64 years, 2 points for age >or=65 years). Predicted mortality (95% confidence interval) for 0, 1, 2, 3, and 4+ point totals was 8% (5% to 14%), 17% (12% to 23%), 31% (26% to 37%), 51% (43% to 58%), and 70% (58% to 80%), respectively. There was an excellent agreement between predicted and observed mortality in the validation cohort. Observed mortality for 0, 1, 2, 3, and 4+ point totals in the validation cohort was 12%, 16%, 28%, 47%, and 67%, respectively. Compared with the Acute Physiology Assessment and Chronic Health Evaluation III score, areas under the receiver operating characteristic curve for the point score were greater in the development cohort (0.72 vs. 0.67, p = 0.09) and lower in the validation cohort (0.68 vs. 0.75, p = 0.03).

CONCLUSIONS

Mortality in patients with ALI can be predicted using an index of four readily available clinical variables with good calibration. This index may help inform prognostic discussions, but validation in nonclinical trial populations is necessary before widespread use.

Cool heads: ethical issues associated with therapeutic hypothermia for newborns

Hypothermia is the first treatment for newborns with hypoxic-ischaemic encephalopathy (HIE) with consistent evidence of a reduction in the risk of death or severe disability. This paper addresses a number of ethical and practical issues faced by clinicians as cooling moves from an experimental treatment into practice. These issues are not unique to therapeutic hypothermia. They include the extrapolation of evidence from trials to clinical care, as well as the impact of hypothermia on prognosis and withdrawal of life-sustaining treatment.

CONCLUSION

Hypothermia is a promising new therapy, but further research will be necessary to help resolve some of the ethical concerns associated with its use in newborns with HIE .

Is certainty more important than diagnosis for understanding race and gender disparities?: an experiment using coronary heart disease and depression case vignettes

OBJECTIVES

To (1) examine the influence of patient and provider attributes on physicians' diagnostic certainty and (2) assess the effect of diagnostic certainty on clinical therapeutic actions.

METHODS

Factorial experiment of 128 generalist physicians using identical clinically authentic videotaped vignettes depicting patients with coronary heart disease (CHD) or depression.

RESULTS

For CHD, physicians were least certain for Black patients (p=.003) and for younger female patients (p=.013). For depression, average certainty was higher than for the CHD presentation (74.0 vs. 57.9 on of scale of 0-100, p<.001) and there were no main effects of patient or provider characteristics. Increasing diagnostic certainty was a significant predictor of subsequent clinical actions, and these varied according to physician and patient characteristics across both conditions.

CONCLUSIONS

Physicians were least certain of their CHD diagnoses for Black patients and for younger women, but patient characteristics alone did not affect physician certainty of depression diagnoses. Physicians responded differentially to diagnostic certainty in terms of their clinical therapeutic actions such as test ordering and writing prescriptions. Physician responses to certainty may be as important as their responses to patient characteristics for understanding variation in clinical decision-making.

Protocol-driven ventilator weaning: reviewing the evidence

Though seminal clinical trials have identified efficacious methods of liberating patients from mechanical ventilation (ie, weaning), this knowledge is not applied often by physicians in routine practice. Weaning protocols are a strategies by which research results can be translated effectively and efficiently into clinical practice, but results of clinical trials evaluating weaning protocols have not been uniform, and controversy continues to surround this important area in critical care medicine. This article reviews the rationale for and against the routine use of weaning protocols and highlights informative details of many clinical trials that have evaluated such protocols.

Factors Associated with Obstetrician-Gynecologists' Response to the Women's Health Initiative Trial of Combined Hormone Therapy

The Women's Health Initiative trial of combined estrogen and progestin (WHI E+P) ended prematurely after preliminary evidence indicated that harms exceeded benefits, with no cardiovascular benefit. There was controversy over the results and the decision to end the trial early, with many obstetrician-gynecologists expressing reservations about the evidence. The Research Department of the American College of Obstetricians and Gynecologists conducted a study regarding the WHI E+P, sending questionnaires to 2500 randomly selected Fellows; 703 Fellows returned usable surveys (28.1%). Despite almost universal awareness of the results of the WHI E+P (> 97%), almost half of the responding physicians did not find the results convincing and disagreed with the decision to stop the trial. In this further examination of the data, we identified characteristics of the respondents who were associated with either accepting or rejecting the WHI E+P. The year residency was completed, the relative importance a respondent attributed to randomized clinical trials (RCTs), concern about harms of action, and opinion of alternative therapies were significant factors. One of 5 respondents found the results convincing and agreed with the decision to end the trial (acceptors). One of 3 respondents did not find the results convincing and disagreed with the decision to end the trial (rejectors). Acceptors had completed residency more recently (1991 v. 1985, P = 0.001), rated evidence from RCTs as more important (P = 0.006), were more concerned with harms of action (22.4% v. 10.6%, P = 0.004), and were more likely to have a favorable opinion of alternative therapies to hormone therapy (64.1% v. 44.4%, P < 0.001).

Pretest risk assessment in suspected acute pulmonary embolism

RATIONALE AND OBJECTIVES

To assess the pretest practices of US clinicians who treat patients with acute pulmonary embolism (PE).

MATERIALS AND METHODS

We surveyed 855 practicing physicians selected randomly from three professional organizations. We asked participants to estimate how often and by what method they determine the likelihood of PE before they request confirmatory studies. Participants reported their awareness of four published clinical practice guidelines dealing with acute PE and selected options for further diagnostic testing after reviewing clinical data from three hypothetical patients presenting with low, intermediate, and high probability of acute PE.

RESULTS

We received completed surveys from 240 physicians practicing in 44 states. Although most (98.3%) report that they assess pretest probability of PE before testing, slightly more than half do so routinely. A total of 72.5% prefer an unstructured approach to pretest assessment, whereas 22.9% use published prediction rules. Most (93.0%) are aware of at least one published guideline for assessing acute PE, but only 44.2% report using one or more in daily practice. Respondents who use published prediction rules, estimate pretest probability routinely, or use at least one practice guideline were more likely to request additional testing when reviewing a low probability clinical scenario. No differences in testing frequency or preferences were observed for intermediate or high probability clinical scenarios.

CONCLUSIONS

The majority of clinicians we surveyed use an unstructured approach when estimating the pretest probability of acute PE. With the exception of low probability scenario, clinicians agreed on testing choices in suspected acute PE, regardless of the method or frequency of pre-test assessment.

Difficult decisions in the intensive care unit: an illustrative case

Difficult clinical decision-making is a common experience in intensive care units. There is often considerable pressure on time and decisions may have to be made in a stressful environment. Patients in the intensive care unit not infrequently present with extreme or rare manifestations of a disease process. Clinical evidence to guide management of such patients may be incomplete, non-existent, or its relevance to the problem at hand may be questionable. In this context, formal decision-making analytical tools are often impractical. Unconscious cognitive biases have been shown to play an important role in medical decision-making, particularly in these settings. While mostly these contribute to doctors making appropriate and timely decisions, occasionally they lead to errors. Despite 30 years of research into models of clinical reasoning, most doctors are unaware of how biases affect their thinking and are unfamiliar with techniques of detecting and neutralising bias in clinical practice. We present the case of a patient with Wegener's granulomatosis, which highlights many of the difficulties outlined above. We review the clinical evidence for our decisions at each stage and explain the rationale for our choices, highlighting the many situations for which high quality evidence was lacking. Examples of cognitive bias are identified and techniques of metacognition (thinking about thinking) that can be useful in limiting the effects of bias on complex decision-making are reviewed. The intensivist's evaluation of management alternatives has an important role in steering medical management towards optimal patient outcomes.

Failure to adopt beneficial therapies caused by bias in medical evidence evaluation

BACKGROUND

Although it is known that many evidence-based therapies are underutilized, the causes of the research-practice gap are not well understood. The authors sought to determine if there is a bias in the evaluation of new evidence that leads to low rates of adoption of beneficial therapies compared to abandonment of harmful ones.

METHODS

Two case vignettes describing hypothetical clinical trials were administered to 2 independent samples of pulmonary and critical care practitioners. Each vignette was presented in 2 different ways; in one version, the results of the hypothetical trial showed that a treatment was harmful, and in the other version, the same treatment was shown to be beneficial. Prospective respondents from each sample were randomized to receive 1 version of each vignette (intersubject design). The main outcome was respondent's willingness to apply the results of the hypothetical trial to patient care.

RESULTS

There were 174 participants for trial 1 and 138 participants for trial 2 (enrollment rates of 44.2% and 41.8%, respectively). For trial 1, respondents were 2.3 times less likely to change clinical practice based on results indicating benefit as opposed to harm (33.3% v. 76.5%; P < 0.0001). Similarly, for trial 2, respondents were 2.57 times less likely to change practice when trial results showed that early use was beneficial as opposed to showing that early use was harmful (37.1% v. 95.3%; P < 0.0001).

CONCLUSIONS

When evaluating clinical trials, physicians demonstrate less willingness to adopt beneficial therapies than to abandon harmful ones. This difference may contribute to the research-practice gap.