Understanding clinical and non-clinical decisions under uncertainty: a scenario-based survey

Attitudes on Equal Health Care Access versus Efficient Clinical Decisions across a Not-for-Profit Health Care System

BACKGROUND

Professional roles within a hospital system may influence attitudes behind clinical decisions.

OBJECTIVE

To determine participants' preferences about clinical decisions that either value equal health care access or efficiency.

DESIGN

Deidentified survey asking participants to choose between offering a low-cost screening test to a whole population ("equal access") or a more sensitive, expensive test that could be given to only half of the population but resulting in 10% more avoided deaths ("efficient"). Data collection took place from August 18, 2021, to January 24, 2022. Study 1644 was determined to be exempt by Tufts Health Sciences Institutional Review Board (IRB).

SETTING

Tufts Medicine Healthcare System.

PARTICIPANTS

Approximately 15,000 hospital employees received an e-mail from the Tufts Medicine Senior Vice President of Academic Integration.

MEASUREMENTS

Analysis of survey responses with chi-square and 1-sample t tests to determine the proportion who chose each option. Logistic regression models fit to examine relationships between professional role and test choice.

RESULTS

A total of 1,346 participants completed the survey (∼9.0% response rate). Overall, approximately equal percentages of respondents chose the "equal access" (48%) and "efficient" option (52%). However, gender, professional role (categorical), and clinical role (dichotomous) were significantly associated with test choice. For example, among those in nonclinical roles, women were more likely than men to choose equal health care access. In multivariable analyses, having clinical roles was significantly associated with 1.73 times the likelihood of choosing equal access (95% confidence interval = 1.33-2.25).

LIMITATIONS

Generalizability concerns and survey question wording limit the study results.

CONCLUSION

Clinicians were more likely than nonclinicians to choose the equal health care access option, and health care administrators were more likely to choose efficiency. These differing attitudes can affect patient care and health care quality.

HIGHLIGHTS

Divergent preferences of valuing equal health care access and efficiency may be in conflict during clinical decision making.In this cross-sectional study that included 1,346 participants, approximately equal percentages of respondents chose the "equal access" (48%) and "efficient" option (52%), a nonsignificant difference. However, gender, professional role (categorical), and clinical role (dichotomous) were significantly associated with test choiceSince clinicians were more likely than nonclinicians to choose the equal health care access option and health care administrators were more likely to choose efficiency, these differing attitudes can affect patient care and health care quality.

A combined behavioural economics- and simulation-based medical education to promote effectiveness among medical residents in coping with workplace violence in Northern China: a quasi-experimental study

BACKGROUND

Workplace violence is internationally recognised as a major concern for the workforce, which entails serious consequences, and research shows that medical residents are more likely than other doctors to experience violence in the workplace. This study first examines the effectiveness of simulation-based medical education, and then simulation-based medical education combined with behavioural economics as interventions in medical residents' perception of, attitude toward, and self-efficacy in coping with violence in the workplace.

METHODS

A quasi-experimental design was used, 190 participants were randomised into three study groups to respectively test the effect of simulation-based medical education only and simulation-based medical education plus behavioural economics interventions, compared with a control group. Data were obtained from structured questionnaires, including (1) a perception of aggression scale, a management of aggression and violence attitude scale, a general self-efficacy scale, and (2) socio-demographic characteristics.

RESULTS

The results show that the scores attained by simulation-based medical education (SBME) and simulation-based medical education combined with behavioural economics (SBME + BE) interventions for perception, attitude, and self-efficacy were significantly higher than those in the control group (p < .01). The SBME + BE group recorded a greater improvement in perception, which could be ascribed to the behavioural economics effect. Furthermore, the higher perception of workplace violence is correlated with single residents and those with more work experience, prior experiences of violence in the workplace, and training related to workplace violence. A higher positive correlation of workplace violence was recorded by female and widowed residents,and a higher level of self-efficacy related to violence in the workplace correlated with male, widowed,and senior (third-year) residents.

CONCLUSIONS

This study contributes important evidence regarding changes in the perception, attitude, and self-efficacy of subjects following both the SBME + BE and SBME interventions among medical residents in coping with workplace violence, the biggest perception change having been recorded after the SBME + BE intervention, which can be explained by the inclusion of behavioural economics.

A cumulative prospect theory-based method for group medical emergency decision-making with interval uncertainty

BACKGROUND

An emergency response to a medical situation is generally considered to be a risk decision-making problem. When an emergency event occurs, it makes sense to take into account more than one decision maker's opinions and psychological behaviors. The existing research tends to ignore these multidimensional aspects. To fill this literature gap, we propose a multi-attribute model.

METHODS

The model is based on cumulative prospect theory (CPT), considering multiple experts' psychological factors. By not assuming full rationality, we extend existing models to allow multiple experts' risk preferences to be incorporated into the decision-making process in the case of an emergency. Then, traditional CPT is extended by allowing for multiple attributes. In addition, rather than using crisp data, interval values are adopted to tackle the usual uncertainties in reality.

RESULTS

The multi-attribute CPT based model proposed can deal with the selection of potential emergency alternatives. The model incorporates interval values to allow more uncertainty and the comparative studies show that the optimal solution changes under different scenarios.

CONCLUSIONS

Our illustrative example and comparative study show that considering multiple experts and multiple attributes is more reasonable, especially in complicated situations under an emergency. In addition, decision-makers' risk preferences highly affect the selection outcomes, highlighting their importance in the medical decision-making process. Our proposed model can be applied to similar fields with appropriate modifications.

Physician Risk Perception and Testing Behaviors for Children With Fever

OBJECTIVES

Risk tolerance and risk perceptions may impact clinicians' decisions to obtain diagnostic tests. We sought to determine whether physician risk perception was associated with the decision to obtain blood or imaging tests among children who present to the emergency department with fever.

METHODS

We conducted a retrospective, cross-sectional study in the Boston Children's Hospital emergency department. We included children aged 6 months to 18 years from May 1, 2014 to April 30, 2019, with fever. Our primary outcome was diagnostic testing: obtaining a blood and/or imaging test. We assessed risk perception using 3 scales: the Risk Tolerance Scale (RTS), Stress From Uncertainty Scale (SUS), and Malpractice Fear Scale (MFS). A z score was assigned to each physician for each scale. Mixed-effects logistic regression assessed the association between physician risk perception and blood or imaging testing. We also examined the relationship between each risk perception scale and several secondary outcomes: blood testing, urine testing, diagnostic imaging, specialist consultation, hospitalization, and revisit within 72 hours.

RESULTS

The response rate was 55/56 (98%). We analyzed 12,527 encounters. Blood/imaging testing varied between physicians (median, 48%; interquartile range, 41%-53%; range, 30%-71%). Risk Tolerance Scale responses were not associated with blood/imaging testing (odds ratio [OR], 1.03 per SD of increased risk perception; 95% confidence interval [CI], 0.95-1.13). Stress From Uncertainty Scale responses were not associated with blood/imaging testing (OR, 1.04 per SD; 95% CI, 0.95-1.14). Malpractice Fear Scale responses were not associated with blood/imaging testing (OR, 1.00 per SD; 95% CI, 0.91-1.09). There was no significant association between RTS, MFS, or SUS and any secondary outcome, except that there was a weak association between SUS and specialist consultation (OR, 1.12; 95% CI, 1.00-1.24).

CONCLUSIONS

Across 55 pediatric emergency physicians with variable testing practices, there was no association between risk perception and blood/imaging testing in febrile children.

How defensive medicine is defined in European medical literature: a systematic review

OBJECTIVES

Defensive medicine has originally been defined as motivated by fear of malpractice litigation. However, the term is frequently used in Europe where most countries have a no-fault malpractice system. The objectives of this systematic review were to explore the definition of the term 'defensive medicine' in European original medical literature and to identify the motives stated therein.

DESIGN

Systematic review.

DATA SOURCES

PubMed, Embase and Cochrane, 3 February 2020, with an updated search on 6 March 2021.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, we reviewed all European original peer-reviewed studies fully or partially investigating 'defensive medicine'.

RESULTS

We identified a total of 50 studies. First, we divided these into two categories: the first category consisting of studies defining defensive medicine by using a narrow definition and the second category comprising studies in which defensive medicine was defined using a broad definition. In 23 of the studies(46%), defensive medicine was defined narrowly as: health professionals' deviation from sound medical practice motivated by a wish to reduce exposure to malpractice litigation. In 27 studies (54%), a broad definition was applied adding … or other self-protective motives. These self-protective motives, different from fear of malpractice litigation, were grouped into four categories: fear of patient dissatisfaction, fear of overlooking a severe diagnosis, fear of negative publicity and unconscious defensive medicine. Studies applying the narrow and broad definitions of defensive medicine did not differ regarding publication year, country, medical specialty, research quality or number of citations.

CONCLUSIONS

In European research, the narrow definition of defensive medicine as exclusively motivated by fear of litigation is often broadened to include other self-protective motives. In order to compare results pertaining to defensive medicine across countries, future studies are recommended to specify whether they are using the narrow or broad definition of defensive medicine.

PROSPERO REGISTRATION NUMBER

CRD42020167215.

At the end: A vignette-based investigation of strategies for managing end-of-life decisions in the intensive care unit

BACKGROUND

Decision-making on end-of-life is an inevitable, yet highly complex, aspect of intensive care decision-making. End-of-life decisions can be challenging both in terms of clinical judgement and social interaction with families, and these two processes often become intertwined. This is especially apparent at times when clinicians are required to seek the views of surrogate decision makers (i.e., family members) when considering palliative care.

METHODS

Using a vignette-based interview methodology, we explored how interactions with family members influence end-of-life decisions by intensive care unit clinicians (n = 24), and identified strategies for reaching consensus with families during this highly emotional phase of care.

RESULTS

We found that the enactment of end-of-life decisions were reported as being affected by a form of loss aversion, whereby concerns over the consequences of not reaching a consensus with families weighed heavily in the minds of clinicians. Fear of conflict with families tended to arise from anticipated unrealistic family expectations of care, family normalization of patient incapacity, and belief systems that prohibit end-of-life decision-making.

CONCLUSIONS

To support decision makers in reaching consensus, various strategies for effective, coherent, and targeted communication (e.g., on patient deterioration and limits of clinical treatment) were suggested as ways to effectively consult with families on end-of-life decision-making.

Barriers and facilitators to reduce low-value care: a qualitative evidence synthesis

OBJECTIVE

To assess barriers and facilitators to de-implementation.

DESIGN

A qualitative evidence synthesis with a framework analysis.

DATA SOURCES

Medline, Embase, Cochrane Library and Rx for Change databases until September 2018 were searched.

ELIGIBILITY CRITERIA

We included studies that primarily focused on identifying factors influencing de-implementation or the continuation of low-value care, and studies describing influencing factors related to the effect of a de-implementation strategy.

DATA EXTRACTION AND SYNTHESIS

The factors were classified on five levels: individual provider, individual patient, social context, organisational context, economic/political context.

RESULTS

We identified 333 factors in 81 articles. Factors related to the individual provider (n=131; 74% barriers, 17% facilitators, 9% both barrier/facilitator) were associated with their attitude (n=72; 55%), knowledge/skills (n=43; 33%), behaviour (n=11; 8%) and provider characteristics (n=5; 4%). Individual patient factors (n=58; 72% barriers, 9% facilitators, 19% both barrier/facilitator) were mainly related to knowledge (n=33; 56%) and attitude (n=13; 22%). Factors related to the social context (n=46; 41% barriers, 48% facilitators, 11% both barrier/facilitator) included mainly professional teams (n=23; 50%) and professional development (n=12; 26%). Frequent factors in the organisational context (n=67; 67% barriers, 25% facilitators, 8% both barrier/facilitator) were available resources (n=28; 41%) and organisational structures and work routines (n=24; 36%). Under the category of economic and political context (n=31; 71% barriers, 13% facilitators, 16% both barrier/facilitator), financial incentives were most common (n=27; 87%).

CONCLUSIONS

This study provides in-depth insight into the factors within the different (sub)categories that are important in reducing low-value care. This can be used to identify barriers and facilitators in low-value care practices or to stimulate development of strategies that need further refinement. We conclude that multifaceted de-implementation strategies are often necessary for effective reduction of low-value care. Situation-specific knowledge of impeding or facilitating factors across all levels is important for designing tailored de-implementation strategies.

Compassionate use of psychedelics

In the present paper, we discuss the ethics of compassionate psychedelic psychotherapy and argue that it can be morally permissible. When talking about psychedelics, we mean specifically two substances: psilocybin and MDMA. When administered under supportive conditions and in conjunction with psychotherapy, therapies assisted by these substances show promising results. However, given the publicly controversial nature of psychedelics, compassionate psychedelic psychotherapy calls for ethical justification. We thus review the safety and efficacy of psilocybin- and MDMA-assisted therapies and claim that it can be rational for some patients to try psychedelic therapy. We think it can be rational despite the uncertainty of outcomes associated with compassionate use as an unproven treatment regime, as the expected value of psychedelic psychotherapy can be assessed and can outweigh the expected value of routine care, palliative care, or no care at all. Furthermore, we respond to the objection that psychedelic psychotherapy is morally impermissible because it is epistemically harmful. We argue that given the current level of understanding of psychedelics, this objection is unsubstantiated for a number of reasons, but mainly because there is no experimental evidence to suggest that epistemic harm actually takes place.

Clinical Genome Data Model (cGDM) provides Interactive Clinical Decision Support for Precision Medicine

In light of recent developments in genomic technology and the rapid accumulation of genomic information, a major transition toward precision medicine is anticipated. However, the clinical applications of genomic information remain limited. This lag can be attributed to several complex factors, including the knowledge gap between medical experts and bioinformaticians, the distance between bioinformatics workflows and clinical practice, and the unique characteristics of genomic data, which can make interpretation difficult. Here we present a novel genomic data model that allows for more interactive support in clinical decision-making. Informational modelling was used as a basis to design a communication scheme between sophisticated bioinformatics predictions and the representative data relevant to a clinical decision. This study was conducted by a multidisciplinary working group who carried out clinico-genomic workflow analysis and attribute extraction, through Failure Mode and Effects Analysis (FMEA). Based on those results, a clinical genome data model (cGDM) was developed with 8 entities and 46 attributes. The cGDM integrates reliability-related factors that enable clinicians to access the reliability problem of each individual genetic test result as clinical evidence. The proposed cGDM provides a data-layer infrastructure supporting the intellectual interplay between medical experts and informed decision-making.

Health care worker perceptions toward computerized clinical decision support tools for Clostridium difficile infection reduction: A qualitative study at 2 hospitals

BACKGROUND

Clostridium difficile infection (CDI) is associated with significant morbidity and mortality. Computerized clinical decision support (CCDS) tools can aid process improvement in infection prevention and antibiotic stewardship, but implementation and health care workers (HCWs) uptake of these tools is often variable. The objective of this study was to describe HCWs' perceptions of barriers and facilitators related to uptake of CCDS tools as part of a CDI reduction bundle.

METHODS

We conducted a qualitative study among HCWs at 2 acute care hospitals in Maryland. Semi-structured interviews and structured surveys were completed by HCWs to evaluate their perception to CCDS tools at 2 different stages: predevelopment and preimplementation. Emergent themes and patterns in the data were identified and condensed.

RESULTS

Gaps in CDI-related knowledge and in communication between HCWs were identified throughout the evaluation. HCWs agreed on the potential of the tools to improve CDI diagnosis, prevention, and control. An important barrier for uptake was the perceived loss of autonomy and clinical judgment, whereas standardization and error reduction were perceived advantages.

CONCLUSIONS

These observations shaped the development and implementation of the CDI reduction bundle. Qualitative findings can provide valuable contextual information during the development stages of CCDS tools in infection prevention and antibiotic stewardship.