Clinician Attitudes and Beliefs Associated with More Aggressive Diagnostic Testing

Urine Testing in Children with Viral Symptoms: A Nationwide Analysis of Ambulatory Visits, 2014-2019

OBJECTIVE

To evaluate the extent of and factors associated with urine testing in US pediatric ambulatory visits for symptoms commonly associated with viral illness.

STUDY DESIGN

We analyzed a nationally representative, cross-sectional sample of ambulatory clinic and emergency department (ED) visits among children 2 months to 17 years old (2014 through 2019 National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey). Using reason for visit classification codes, we identified visits for respiratory symptoms, diarrhea, or rash; termed "viral symptoms" without reported localizing genitourinary symptoms. We assessed the proportion of these visits with urine testing (urinalysis and/or urine culture) and evaluated factors associated with urine testing using logistic regression.

RESULTS

Of 71.3 million (95% CI 64.7-78.0 million) pediatric ambulatory visits per year, 61% (95% CI 59%-63%) were for viral symptoms without reported genitourinary symptoms. Urine testing at these visits accounted for 38% (95% CI 30%-47%) of overall urine testing. Such testing occurred more frequently at ED visits (8.3%; 95% CI 7.4%-9.3%) compared with clinic visits (4.4%; 95% CI 2.5%-7.7%). At ED visits, the adjusted probability of urine testing in the context of viral symptoms was lowest for males age 2 months to <2 years (5%; 95% CI 3%-6%) and highest for females age 12 through 17 years (20%; 95% CI 16%-24%), and females age 6-11 years (13%; 95% CI 11%-16%).

CONCLUSIONS

Urine testing in children with symptoms of viral or other non-urinary tract infection illnesses occurs frequently at ambulatory visits. This potentially avoidable testing disproportionately occurred in older age groups that have lower risk of urinary tract infection.

Impact of antibiotic treatment and predictors for subsequent infections in multidrug-resistant Pseudomonas aeruginosa catheter-associated asymptomatic bacteriuria

BACKGROUND

The rate of antibiotic treatment for catheter-associated asymptomatic bacteriuria (CA-ASB) remains high.

METHODS

We conducted a retrospective study involving hospitalized patients with multidrug-resistant Pseudomonas aeruginosa (MDRP) CA-ASB. Cox proportional hazards regression models were used to identify predictors for subsequent symptomatic infections in patients with MDRP CA-ASB. The probability of remaining free from symptomatic infection was analyzed using Kaplan-Meier curves.

RESULTS

The study cohort comprised 139 patients with MDRP CA-ASB. Subsequent symptomatic MDRP infections were observed in 37 (26.6%) patients. Multivariate analysis revealed that underlying urologic diseases (hazard ratio [HR]=2.17, 95% confidence interval [CI]=1.01-4.66, P=.047), active antibiotic treatment for MDRP (HR=2.34, 95% CI=1.02-5.38, P=.046), and recurrent bacteriuria (HR=3.57, 95% CI=1.73-7.38, P=.001) were independent predictors for subsequent symptomatic infections. The Kaplan-Meier analysis demonstrated a significantly lower cumulative proportion of symptomatic infection-free patients among those receiving active antibiotic therapy for MDRP CA-ASB than among those who did not (41.7% vs 76.4%, P=.006, log-rank test).

CONCLUSIONS

These findings support the current guidelines against routine antibiotic therapy, even for MDRP CA-ASB, and emphasize the need for close monitoring and timely intervention in high-risk populations.

De-implementing low-value care in emergency medicine: A framework for sustainable improvement

The continued use of low-value care interventions is a persisting challenge across the healthcare system despite targeted international efforts to reduce their use. These practices result in considerable economic and carbon costs. We present a model used to successfully de-implement four low-value care practices in a tertiary ED in Victoria, Australia. We outline the interventions and the proportions by which they were reduced. We provide a step-by-step framework that provides a model for other hospital departments or primary care centres to initiate their own de-implementation process for low-value care practices within their setting.

What Clinicians Think About When They Think About Sepsis: Results From a Survey Across the University of Maryland Medical System

IMPORTANCE

Sepsis, a leading cause of death in the hospital, is a heterogeneous syndrome without a defined or specific set of symptoms.

OBJECTIVES

We conducted a survey of clinicians in practice to understand which clinical findings they tend to associate with sepsis.

DESIGN, SETTING, AND PARTICIPANTS

A survey was distributed to physicians and advanced practice providers across a multihospital health system during April 2022 and May 2022 querying likelihood of suspecting sepsis and initiating sepsis care in response to various normal and abnormal clinical findings.

ANALYSIS

Strength of association between clinical findings and suspicion of sepsis were based on median and interquartile range of complete responses. Comparisons between individual questions were performed using Wilcoxon rank-sum testing.

RESULTS

Among 179 clinicians who opened the survey, 68 (38%) completed all questions, including 53 (78%) attending physicians representing six different hospitals. Twenty-nine respondents (43%) worked primarily in the ICU, and 16 (24%) worked in the emergency department. The clinical findings most strongly associated with suspicion of sepsis were hypotension, tachypnea, coagulopathy, leukocytosis, respiratory distress, and fever. The abnormal clinical findings least likely to prompt suspicion for sepsis were elevated bilirubin, elevated troponin, and abdominal examination suggesting ileus. On average, respondents were more likely to suspect sepsis with high temperature than with low temperature (p = 0.008) and with high WBC count than with low WBC count (p = 0.003).

CONCLUSIONS

Clinicians in practice tend to associate the diagnosis of sepsis with signs of severe illness, such as hypotension or respiratory distress, and systemic inflammation, such as fever and leukocytosis. Except for coagulopathy, nonspecific laboratory indicators of organ dysfunction have less influence on decision-making.

The paradox of convenience: how information overload in mHealth apps leads to medical service overuse

Background

Mobile health applications (mHealth) have become an indispensable tool in the healthcare industry to provide users with efficient and convenient health services. However, information overload has led to significant information overload problems in mHealth applications, which may further lead to overuse of medical services.

Methods

The purpose of this study was to explore the relationship between information overload and overuse of medical services in mHealth applications through health belief model (HBM). Data were collected from 1,494 respondents who were sampled through a simple random approach. A structured questionnaire was used as the instrument for data collection from mobile APP users in Guangdong Province between February 4, 2024, and February 20, 2024. Structural equation modeling (SEM) was used to analyze the data to investigate the effects of information overload on users' perceived severity, susceptibility, treatment benefits, barriers, self-efficacy, and action cues, which further influence the overuse of health care services.

Results

The study found that information overload significantly affected users' perceived severity, susceptibility, treatment benefits, barriers, self-efficacy, and action cues, and subsequently affected overuse of health care services. These results provide valuable insights for mHealth application developers, healthcare providers, and policy makers.

Conclusion

This study highlights the importance of effectively managing information delivery in mHealth applications to reduce the risk of overuse of healthcare services. The study not only highlights the dark side of information overload in mHealth applications, but also provides a framework to understand and address the challenges associated with information overload and service overuse in the mHealth context.

Surgeon Preference for Maximizing Medical Care Is Associated with Recommending More Extensive Surgery for Low-Risk Thyroid Cancer

Background: While patient-level determinants of total thyroidectomy use have been well described, surgeon-level drivers of more extensive surgery are present and less well described. This survey sought to examine the associations between surgeons' operative recommendations, their beliefs about cancer, and their attitudes about medical maximizing-minimizing. Methods: A mixed-mode, cross-sectional survey was administered in September 2020 via mail and email to 222 thyroid surgeons identified in the Centers for Medicare & Medicaid Services Provider Utilization and Payment Physician and Other Practitioners dataset. Participants were asked their treatment recommendation for a healthy 45-year-old woman with a solitary 2.0-cm papillary thyroid cancer. Surgeons were assessed with the Brief Worry Scale and a validated, single-item measure of cancer-related worry. The Clinician Maximizer-Minimizer scale was used to assess the extent of medical care that physicians tend to favor with their patients. Participants were categorized into terciles based on their responses to the Maximizer-Minimizer scale. The highest scoring tercile ("Maximizers") was compared with the two lower terciles by Student's t-tests, chi-square, ANOVA, and logistic regression. Results: Of the 149 surgeons (response rate 67.1%), 34.9% recommended total thyroidectomy with or without central neck dissection (CND), and 65.1% recommended lobectomy. Overall, the medical Maximizer-Minimizer scale had an average score of 24.6 (SD 6.8). There were no differences between surgeons' age, race, annual thyroidectomy volume, or practice setting by their Maximizer-Minimizer classification. Participants who recommended total thyroidectomy with or without CND had significantly higher Maximizer-Minimizer scores than those recommending lobectomy (25.9 ± 7.2 vs. 23.8 ± 6.4, p = 0.03). Those classified as maximizers also had more cancer-related worry on both the single-item and Brief Worry Scales (p = 0.02). On logistic regression controlling for age, sex, race, specialty training, practice setting, and annual thyroidectomy volume, maximizers were still more likely to recommend total thyroidectomy with or without a CND (OR 2.4, [CI 1.01-5.55], p = 0.047). Conclusions: Medical maximizing-minimizing tendencies represent one of potentially many unmeasured surgeon characteristics that may explain persistent patterns of over-diagnosis, over-treatment, and over-screening. Surgeons may benefit from awareness of how their own tendencies influence their surgical recommendations in patients with low-risk thyroid cancer.

Game-based learning to improve diagnostic accuracy: a pilot randomized-controlled trial

OBJECTIVES

Perform a pilot study of online game-based learning (GBL) using natural frequencies and feedback to teach diagnostic reasoning.

METHODS

We conducted a multicenter randomized-controlled trial of computer-based training. We enrolled medical students, residents, practicing physicians and nurse practitioners. The intervention was a 45 min online GBL training vs. control education with a primary outcome of score on a scale of diagnostic accuracy (composed of 10 realistic case vignettes, requesting estimates of probability of disease after a test result, 0-100 points total).

RESULTS

Of 90 participants there were 30 students, 30 residents and 30 practicing clinicians. Of these 62 % (56/90) were female and 52 % (47/90) were white. Sixty were randomized to GBL intervention and 30 to control. The primary outcome of diagnostic accuracy immediately after training was better in GBL (mean accuracy score 59.4) vs. control (37.6), p=0.0005. The GBL group was then split evenly (30, 30) into no further intervention or weekly emails with case studies. Both GBL groups performed better than control at one-month and some continued effect at three-month follow up. Scores at one-month GBL (59.2) GBL plus emails (54.2) vs. control (33.9), p=0.024; three-months GBL (56.2), GBL plus emails (42.9) vs. control (35.1), p=0.076. Most participants would recommend GBL to colleagues (73 %), believed it was enjoyable (92 %) and believed it improves test interpretation (95 %).

CONCLUSIONS

In this pilot study, a single session with GBL nearly doubled score on a scale of diagnostic accuracy in medical trainees and practicing clinicians. The impact of GBL persisted after three months.

Bacteremia From a Presumed Urinary Source in Hospitalized Adults With Asymptomatic Bacteriuria

Importance

Guidelines recommend withholding antibiotics in asymptomatic bacteriuria (ASB), including among patients with altered mental status (AMS) and no systemic signs of infection. However, ASB treatment remains common.

Objectives

To determine prevalence and factors associated with bacteremia from a presumed urinary source in inpatients with ASB with or without AMS and estimate antibiotics avoided if a 2% risk of bacteremia were used as a threshold to prompt empiric antibiotic treatment of ASB.

Design, Setting, and Participants

This cohort study assessed patients hospitalized to nonintensive care with ASB (no immune compromise or concomitant infections) in 68 Michigan hospitals from July 1, 2017, to June 30, 2022. Data were analyzed from August 2022 to January 2023.

Main Outcomes and Measures

The primary outcome was prevalence of bacteremia from a presumed urinary source (ie, positive blood culture with matching organisms within 3 days of urine culture). To determine factors associated with bacteremia, we used multivariable logistic regression models. We estimated each patient's risk of bacteremia and determined what percentage of patients empirically treated with antibiotics had less than 2% estimated risk of bacteremia.

Results

Of 11 590 hospitalized patients with ASB (median [IQR] age, 78.2 [67.7-86.6] years; 8595 female patients [74.2%]; 2235 African American or Black patients [19.3%], 184 Hispanic patients [1.6%], and 8897 White patients [76.8%]), 8364 (72.2%) received antimicrobial treatment for UTI, and 161 (1.4%) had bacteremia from a presumed urinary source. Only 17 of 2126 patients with AMS but no systemic signs of infection (0.7%) developed bacteremia. On multivariable analysis, male sex (adjusted odds ratio [aOR], 1.45; 95% CI, 1.02-2.05), hypotension (aOR, 1.86; 95% CI, 1.18-2.93), 2 or more systemic inflammatory response criteria (aOR, 1.72; 95% CI, 1.21-2.46), urinary retention (aOR, 1.87; 95% CI, 1.18-2.96), fatigue (aOR, 1.53; 95% CI, 1.08-2.17), log of serum leukocytosis (aOR, 3.38; 95% CI, 2.48-4.61), and pyuria (aOR, 3.31; 95% CI, 2.10-5.21) were associated with bacteremia. No single factor was associated with more than 2% risk of bacteremia. If 2% or higher risk of bacteremia were used as a cutoff for empiric antibiotics, antibiotic exposure would have been avoided in 78.4% (6323 of 8064) of empirically treated patients with low risk of bacteremia.

Conclusions and Relevance

In patients with ASB, bacteremia from a presumed urinary source was rare, occurring in less than 1% of patients with AMS. A personalized, risk-based approach to empiric therapy could decrease unnecessary ASB treatment.

Understanding and Implementing Diagnostic Stewardship: A Guide for Resident Physicians in the Era of Antimicrobial Resistance

Antimicrobial resistance (AMR) poses a significant global health challenge, exacerbated by the COVID-19 pandemic. Antimicrobial stewardship programs (ASPs) are crucial in managing this crisis, with diagnostic stewardship (DS) emerging as a key component. DS refers to the appropriate use of diagnostic tests to optimize patient outcomes, improve antimicrobial use, and combat multi-drug-resistant (MDR) organisms. Despite its potential, understanding and application of DS remain ambiguous in multiple respects, which, however, do not directly implicate the implementation of such initiatives. DS is particularly important for resident physicians who are often at the forefront of patient care and can significantly influence future AMR strategies. This review provides a comprehensive overview of DS, discussing its importance, potential challenges, and future directions. It emphasizes the need for resident physicians to understand DS principles and integrate them into their clinical practice from the beginning of their careers. The review also highlights the role of various stakeholders in implementing DS and the importance of continuous education and training. Ultimately, DS is not just a clinical tool but a philosophy of care, essential for a more responsive, humane, and effective healthcare system.

Developing a diagnosis calculator to estimate the probability of bacterial pneumonia

Misdiagnosis of bacterial pneumonia increases risk of exposure to inappropriate antibiotics and adverse events. We developed a diagnosis calculator (https://calculator.testingwisely.com) to inform clinical diagnosis of community-acquired bacterial pneumonia using objective indicators, including incidence of disease, risk factors, and sensitivity and specificity of diagnostic tests, that were identified through literature review.

Factors Associated With Clinician Self-Reported Resource Use in Acute Care and Ambulatory Pediatrics

The objective of this study is to determine predictors of resource use among pediatric providers for common respiratory illnesses. We surveyed pediatric primary care, emergency department (ED)/urgent care (UC), and hospital medicine providers at a free-standing children's hospital system. Five clinical vignettes assessed factors affecting resource use for upper respiratory infections, bronchiolitis, and pneumonia, including provider-type, practice location, tolerance to uncertainty, and medical decision-making behaviors. The response rate was 75.3% (168/223). The ED/UC and primary care providers had higher vignette scores, indicating higher resource use, compared with inpatient providers; advanced practice providers (APPs) had higher vignette scores compared with physicians. In multivariate analysis, being an ED/UC provider, an APP, and greater concern for bad outcomes were associated with higher vignette scores. Overall, provider type and location of practice may predict resource use for children with respiratory illnesses. Interventions targeted at test-maximizing providers may improve quality of care and reduce resource burden.

Understanding healthcare provider preferences for ordering respiratory cultures to diagnose ventilator associated pneumonia: A discrete choice experiment

OBJECTIVE

Ventilator-associated pneumonia (VAP) can be overdiagnosed on the basis of positive respiratory cultures in the absence of clinical findings of pneumonia. We determined the perceived diagnostic importance of 6 clinical attributes in ordering a respiratory culture to identify opportunities for diagnostic stewardship.

DESIGN

A discrete choice experiment presented participants with a vignette consisting of the same "stem" plus variations in 6 clinical attributes associated with VAP: chest imaging, oxygenation, sputum, temperature, white blood cell count, and blood pressure. Each attribute had 3-4 levels, resulting in 32 total scenarios. Participants indicated whether they would order a respiratory culture, and if yes, whether they preferred the bronchoalveolar lavage or endotracheal aspirate sample-collection method. We calculated diagnostic utility of attribute levels and relative importance of each attribute.

SETTING AND PARTICIPANTS

The survey was administered electronically to critical-care clinicians via a Qualtrics survey at a tertiary-care academic center in the United States.

RESULTS

In total, 59 respondents completed the survey. New radiograph opacity (utility, 1.15; 95% confidence interval [CI], 0.99-1.3), hypotension (utility, 0.88; 95% CI, 0.74-1.03), fever (utility, 0.76; 95% CI, 0.62-0.91) and copious sputum (utility, 0.75; 95% CI, 0.60-0.90) had the greatest perceived diagnostic value that favored ordering a respiratory culture. Radiograph changes (23%) and temperature (20%) had the highest relative importance. New opacity (utility, 0.35; 95% CI, 0.17-0.52) and persistent opacity on radiograph (utility, 0.32; 95% CI, 0.05-0.59) had the greatest value favoring bronchoalveolar lavage over endotracheal aspirate.

CONCLUSION

Perceived high diagnostic value of fever and hypotension suggest that sepsis vigilance may drive respiratory culturing and play a role in VAP overdiagnosis.

Exploration of Primary Care Clinician Attitudes and Cognitive Characteristics Associated With Prescribing Antibiotics for Asymptomatic Bacteriuria

Importance

Antibiotic treatment for asymptomatic bacteriuria is not recommended in guidelines but is a major driver of inappropriate antibiotic use.

Objective

To evaluate whether clinician culture and personality traits are associated with a predisposition toward inappropriate prescribing.

Design, Setting, and Participants

This survey study involved secondary analysis of a previously completed survey. A total of 723 primary care clinicians in active practice in Texas, the Mid-Atlantic, and the Pacific Northwest, including physicians and advanced practice clinicians, were surveyed from June 1, 2018, to November 26, 2019, regarding their approach to a hypothetical patient with asymptomatic bacteriuria. Clinician culture was represented by training background and region of practice. Attitudes and cognitive characteristics were represented using validated instruments to assess numeracy, risk-taking preferences, burnout, and tendency to maximize care. Data were analyzed from November 8, 2021, to March 29, 2022.

Interventions

The survey described a male patient with asymptomatic bacteriuria and changes in urine character. Clinicians were asked to indicate whether they would prescribe antibiotics.

Main Outcomes and Measures

The main outcome was self-reported willingness to prescribe antibiotics for asymptomatic bacteriuria. Willingness to prescribe antibiotics was hypothesized to be associated with clinician characteristics, background, and attitudes, including orientation on the Medical Maximizer-Minimizer Scale. Individuals with a stronger orientation toward medical maximizing prefer treatment even when the value of treatment is ambiguous.

Results

Of the 723 enrolled clinicians, 551 (median age, 32 years [IQR, 29-44 years]; 292 [53%] female; 296 [54%] White) completed the survey (76% response rate), including 288 resident physicians, 202 attending physicians, and 61 advanced practice clinicians. A total of 303 respondents (55%) were from the Mid-Atlantic, 136 (25%) were from Texas, and 112 (20%) were from the Pacific Northwest. A total of 392 clinicians (71% of respondents) indicated that they would prescribe antibiotic treatment for asymptomatic bacteriuria in the absence of an indication. In multivariable analyses, clinicians with a background in family medicine (odds ratio [OR], 2.93; 95% CI, 1.53-5.62) or a high score on the Medical Maximizer-Minimizer Scale (indicating stronger medical maximizing orientation; OR, 2.06; 95% CI, 1.38-3.09) were more likely to prescribe antibiotic treatment for asymptomatic bacteriuria. Resident physicians (OR, 0.57; 95% CI, 0.38-0.85) and clinicians in the Pacific Northwest (OR, 0.49; 95% CI, 0.33-0.72) were less likely to prescribe antibiotics for asymptomatic bacteriuria.

Conclusions and Relevance

The findings of this survey study suggest that most primary care clinicians prescribe inappropriate antibiotic treatment for asymptomatic bacteriuria in the absence of risk factors. This tendency is more pronounced among family medicine physicians and medical maximizers and is less common among resident physicians and clinicians in the US Pacific Northwest. Clinician characteristics should be considered when designing antibiotic stewardship interventions.