Clinical Judgement Analysis: An innovative approach to explore the individual decision-making processes of pharmacists

The RepVig framework for designing use-case specific representative vignettes and evaluating triage accuracy of laypeople and symptom assessment applications

Most studies evaluating symptom-assessment applications (SAAs) rely on a common set of case vignettes that are authored by clinicians and devoid of context, which may be representative of clinical settings but not of situations where patients use SAAs. Assuming the use case of self-triage, we used representative design principles to sample case vignettes from online platforms where patients describe their symptoms to obtain professional advice and compared triage performance of laypeople, SAAs (e.g., WebMD or NHS 111), and Large Language Models (LLMs, e.g., GPT-4 or Claude) on representative versus standard vignettes. We found performance differences in all three groups depending on vignette type: When using representative vignettes, accuracy was higher (OR = 1.52 to 2.00, p < .001 to .03 in binary decisions, i.e., correct or incorrect), safety was higher (OR = 1.81 to 3.41, p < .001 to .002 in binary decisions, i.e., safe or unsafe), and the inclination to overtriage was also higher (OR = 1.80 to 2.66, p < .001 to p = .035 in binary decisions, overtriage or undertriage error). Additionally, we found changed rankings of best-performing SAAs and LLMs. Based on these results, we argue that our representative vignette sampling approach (that we call the RepVig Framework) should replace the practice of using a fixed vignette set as standard for SAA evaluation studies.

Prescribing hand strengthening exercise for patients with rheumatoid arthritis; clinical cues influencing occupational therapists' and physiotherapists' judgements

OBJECTIVE

To explore the clinical judgements of therapists in prescribing the intensity of hand strengthening exercise in rheumatoid arthritis (RA).

METHODS

Phase I: Eleven therapists knowledgeable in treating patients with RA subjectively identified seven clinical cues. These were incorporated into 54 hypothetical patient case scenarios.

PHASE II

Therapists with ≥2 years post-registration experience and current or recent experience in treating patients with RA were asked to assess 69 case scenarios in total (54 + 15 repeats) and judge what intensity of hand strengthening exercise they would prescribe using the OMNI-Resistance Exercise Scale of perceived exertion. Using responses to the repeated cases, the Cochran-Weiss-Shanteau index of expertise was used to identify therapists who prescribed more consistently. Multiple regression was used to determine which clinical cues were most strongly associated with the intensity of exercise prescribed. A sub-group analysis explored differences between consistent and inconsistent prescribers.

RESULTS

Fifty-three therapists took part. Thirty completed all 69 case scenarios. Across all therapists, the three most important clinical cues associated with lower intensity of exercise prescribed were (1) Patient's reported pain intensity whilst practising the exercise (β = -1.150, p < 0.001), (2) Disease activity (β = -0.425, p < 0.001) and (3) average hand pain over the last week (β = -0.353 p < 0.001). Twelve therapists were categorised as consistent prescribers. This group relied on fewer clinical cues (three vs. seven) when judging what intensity of exercise to prescribe.

CONCLUSION

This study provides insights into how therapists prescribe hand exercises. Intensity of hand strengthening exercise was influenced by three key clinical cues, including pain intensity and disease activity.

Exploring Pharmacists' Roles during the 2019-2020 Australian Black Summer Bushfires

Background: Australians are no strangers to sudden natural disasters, such as bushfires. The effects of a natural disaster can devastate local communities and health care services. Currently, limited research has explored the role of the pharmacist during a natural disaster. This study explores the role of the Australian pharmacist during the 2019/2020 Black Summer Bushfires. Methods: Semi-structured phone interviews were conducted with ten community pharmacists who worked through the Black Summer Bushfires whose daily tasks and work environment were directly affected by the bushfires. Thematic analysis using NVivo^®, a qualitative data analysis software was conducted. Results: Analysis of the transcripts generated six main themes: collaboration; trauma and mental health; power and communication; acute presentations; triaging and emergency prescribing. Pharmacists worked in close collaboration with doctors and members of the local community. They provided triaging services, timely health advice about chronic health problems, and managed acute issues, including wound and burn management and mental health support in traumatic conditions, sometimes without power and communication amenities. The challenges presented to pharmacists during the bushfires warranted creative and flexible approaches at times. Conclusion: This study highlights the need for mental health support and training for pharmacists, provisional prescribing privileges, and a clearer set of contingency regulations and legislation related to emergencies and natural disasters. Further research is warranted to gain greater insight into the roles undertaken by Australian pharmacists during natural disasters and their autonomy in decision making processes during such times.