Patient-Physician Fit: An Exploratory Study of a Multidimensional Instrument

Background. Patients face difficulty selecting physicians because they have little knowledge of how physicians’ behaviors fit with their own preferences. Objective. To develop scales of patient and physician behavior preferences and determine whether patient-physician fit is associated with patient satisfaction. Design. Two cross-sectional surveys of patients and providers. Setting. Ambulatory clinics at a university medical center. Participants. Eight general internists, 14 family physicians, and 193 patients. Measurements. Two instruments were developed to measure 6 preferences for physician behaviors: 1) considering nonmedical aspects of the patient’s life, 2) familiarity with herbal medicine, 3) physician decision making, 4) providing information, 5) considering the patient’s religion, and 6) treating what the patient perceives as his or her problem. Patients reported how they would prefer physicians to behave, and physicians reported how they preferred to behave. Patients also rated satisfaction with their physician. Results. Post hoc tests found that as a group, patients scored higher than physicians in preference for the physician to provide information and lower in preference for considering nonmedical aspects of the patient’s life and religious beliefs. As hypothesized, preference differences accounted for significant variance in satisfaction in overall tests (19% in the family medicine patients and 25% in internal medicine patients). Greater satisfaction was associated with fit between patient and physician preferences for physician decision making (in the internal medicine patients) and with fit in providing information and consideration of religion (in family medicine patients) Conclusions. Patients often prefer behaviors other than how their physicians prefer to behave. Preference fit is associated with enhanced patient satisfaction. Physicians should attend to whether patients want religion and other nonmedical aspects of their lives considered. Health plans may wish to provide tools to help patients choose physicians by fit

Medical Problem Solving

This essay reviews the origins, findings and influence of the monograph Medical Problem Solving: An Analysis of Clinical Reasoning. Majorfindings of the monograph are reviewed in the light of subsequent work and the results of selected studies of clinical cognition are related to the book's conclusions, thus sketching the growth of this field of research in the decade since publication. Several remaining methodologicalproblems and scholarly issues in the field are discussed, including: sampling cases and subjects, the definition of medical expertise, the role of verbal report in analyzing thinking, the level of clinical realism needed in research, and the relation of informationprocessing approaches to more quantitative approaches such as behavioral decision theory and social judgment theory.

Discharge Planning Decision Making by Hospitalized Patients

Although studies have examined decision making in discharge planning, few have studied the decision-making process from the patient's perspective. Using structured cases, this pilot study examined patients'decisions fordischarge planning. Four variables were manipulated to create 24 unique cases. These variables included patient living situation, personal assistance needs, home assistance needs, and complexity of medication regime. Respondents rank ordered the appropriateness of four discharge options (i.e., outpatient clinic, housekeeping/chore, home health nursing, and nursing home care) for each case. Eighty chronically ill hospitalized patients from two VA hospitals served as subjects. Patient living arrangement, home assistance needs, and personal assistance needs had strong relationships with the perceived appropriateness of outpatient and nursing home care. When patient status was good, nursing home care was clearly an inappropriate solution from the patients' perspective. Outpatient care was ranked as less appropriate when patient status deteriorated. The only significant association with home health care was personal assistance needs. Medication complexity had no significant association with the four discharge options.

Risk as feelings in the effect of patient outcomes on physicians' future treatment decisions: a randomized trial and manipulation validation

The present study tested predictions derived from the Risk as Feelings hypothesis about the effects of prior patients' negative treatment outcomes on physicians' subsequent treatment decisions. Two experiments at The University of Chicago, U.S.A., utilized a computer simulation of an abdominal aortic aneurysm (AAA) patient with enhanced realism to present participants with one of three experimental conditions: AAA rupture causing a watchful waiting death (WWD), perioperative death (PD), or a successful operation (SO), as well as the statistical treatment guidelines for AAA. Experiment 1 tested effects of these simulated outcomes on (n = 76) laboratory participants' (university student sample) self-reported emotions, and their ratings of valence and arousal of the AAA rupture simulation and other emotion-inducing picture stimuli. Experiment 2 tested two hypotheses: 1) that experiencing a patient WWD in the practice trial's experimental condition would lead physicians to choose surgery earlier, and 2) experiencing a patient PD would lead physicians to choose surgery later with the next patient. Experiment 2 presented (n = 132) physicians (surgeons and geriatricians) with the same experimental manipulation and a second simulated AAA patient. Physicians then chose to either go to surgery or continue watchful waiting. The results of Experiment 1 demonstrated that the WWD experimental condition significantly increased anxiety, and was rated similarly to other negative and arousing pictures. The results of Experiment 2 demonstrated that, after controlling for demographics, baseline anxiety, intolerance for uncertainty, risk attitudes, and the influence of simulation characteristics, the WWD experimental condition significantly expedited decisions to choose surgery for the next patient. The results support the Risk as Feelings hypothesis on physicians' treatment decisions in a realistic AAA patient computer simulation. Bad outcomes affected emotions and decisions, even with statistical AAA rupture risk guidance present. These results suggest that bad patient outcomes cause physicians to experience anxiety and regret that influences their subsequent treatment decision-making for the next patient.

Diagnostic error in medicine: analysis of 583 physician-reported errors

BACKGROUND

Missed or delayed diagnoses are a common but understudied area in patient safety research. To better understand the types, causes, and prevention of such errors, we surveyed clinicians to solicit perceived cases of missed and delayed diagnoses.

METHODS

A 6-item written survey was administered at 20 grand rounds presentations across the United States and by mail at 2 collaborating institutions. Respondents were asked to report 3 cases of diagnostic errors and to describe their perceived causes, seriousness, and frequency.

RESULTS

A total of 669 cases were reported by 310 clinicians from 22 institutions. After cases without diagnostic errors or lacking sufficient details were excluded, 583 remained. Of these, 162 errors (28%) were rated as major, 241 (41%) as moderate, and 180 (31%) as minor or insignificant. The most common missed or delayed diagnoses were pulmonary embolism (26 cases [4.5% of total]), drug reactions or overdose (26 cases [4.5%]), lung cancer (23 cases [3.9%]), colorectal cancer (19 cases [3.3%]), acute coronary syndrome (18 cases [3.1%]), breast cancer (18 cases [3.1%]), and stroke (15 cases [2.6%]). Errors occurred most frequently in the testing phase (failure to order, report, and follow-up laboratory results) (44%), followed by clinician assessment errors (failure to consider and overweighing competing diagnosis) (32%), history taking (10%), physical examination (10%), and referral or consultation errors and delays (3%).

CONCLUSIONS

Physicians readily recalled multiple cases of diagnostic errors and were willing to share their experiences. Using a new taxonomy tool and aggregating cases by diagnosis and error type revealed patterns of diagnostic failures that suggested areas for improvement. Systematic solicitation and analysis of such errors can identify potential preventive strategies.

Thinking about diagnostic thinking: a 30-year perspective

This paper has five objectives: (a) to review the scientific background of, and major findings reported in, Medical Problem Solving, now widely recognized as a classic in the field; (b) to compare these results with some of the findings in a recent best-selling collection of case studies; (c) to summarize criticisms of the hypothesis-testing model and to show how these led to greater emphasis on the role of clinical experience and prior knowledge in diagnostic reasoning; (d) to review some common errors in diagnostic reasoning; (e) to examine strategies to reduce the rate of diagnostic errors, including evidence-based medicine and systematic reviews to augment personal knowledge, guidelines and clinical algorithms, computer-based diagnostic decision support systems and second opinions to facilitate deliberation, and better feedback.

Clinical ethical dilemmas: convergent and divergent views of two scholarly communities

OBJECTIVE

To survey members of the American Society for Bioethics and Humanities (ASBH; n = 327) and of the Society for Medical Decision Making (SMDM; n = 77) to elicit the similarities and differences in their reasoning about two clinical cases that involved ethical dilemmas.

CASES

Case 1 was that of a patient refusing treatment that a surgeon thought would be beneficial. Case 2 dealt with end-of-life care. The argument was whether intensive treatment should be continued of an unconscious patient with multiorgan failure.

METHOD

Four questions, with structured multiple alternatives, were asked about each case: identified core problems, needed additional information, appropriate next steps and who the decision maker should be.

OBSERVATIONS AND RESULTS

Substantial similarities were noticed between the two groups in identifying the core problems, the information needed and the appropriate next steps. SMDM members gave more weight to outcomes and trade-offs and ASBH members had patient autonomy trump other considerations more strongly. In case 1, more than 60% of ASBH respondents identified the patient alone as the decision maker, whereas members of SMDM were almost evenly divided between having the patient as the solo decision maker or preferring a group of some sort as the decision maker, a significant difference (p<0.02). In case 2, both groups agreed that the question of discontinuing treatment should be discussed with the family and that the family alone should not be the decision maker.

CONCLUSION

Despite distinctively different methods of case analysis and little communication between the two professional communities, many similarities were observed in the actual decisions they reached on the two clinical dilemmas.

Do physicians know when their diagnoses are correct? Implications for decision support and error reduction

OBJECTIVE

This study explores the alignment between physicians' confidence in their diagnoses and the "correctness" of these diagnoses, as a function of clinical experience, and whether subjects were prone to over-or underconfidence.

DESIGN

Prospective, counterbalanced experimental design.

SETTING

Laboratory study conducted under controlled conditions at three academic medical centers.

PARTICIPANTS

Seventy-two senior medical students, 72 senior medical residents, and 72 faculty internists.

INTERVENTION

We created highly detailed, 2-to 4-page synopses of 36 diagnostically challenging medical cases, each with a definitive correct diagnosis. Subjects generated a differential diagnosis for each of 9 assigned cases, and indicated their level of confidence in each diagnosis.

MEASUREMENTS AND MAIN RESULTS

A differential was considered "correct" if the clinically true diagnosis was listed in that subject's hypothesis list. To assess confidence, subjects rated the likelihood that they would, at the time they generated the differential, seek assistance in reaching a diagnosis. Subjects' confidence and correctness were "mildly" aligned (kappa=.314 for all subjects, .285 for faculty, .227 for residents, and .349 for students). Residents were overconfident in 41% of cases where their confidence and correctness were not aligned, whereas faculty were overconfident in 36% of such cases and students in 25%.

CONCLUSIONS

Even experienced clinicians may be unaware of the correctness of their diagnoses at the time they make them. Medical decision support systems, and other interventions designed to reduce medical errors, cannot rely exclusively on clinicians' perceptions of their needs for such support.

Patients' values and clinical substituted judgments: The case of localized prostate cancer

The authors examined agreement between patients' utilities and importance rankings and clinicians' judgments of these assessments using a multiattribute model representing 6 aspects of health states potentially associated with localized prostate cancer. Patients were interviewed individually shortly after diagnosis and at a follow-up visit to obtain time-tradeoff utilities for 4 health states, including current health, and importance ranks of the 6 attributes. Their clinicians independently provided views of what utilities and importance ranks would be in the patient's best interest. Using patient-clinician pairs as the unit of analysis, the authors discovered that only about 50% of the correlations across 4 health states were high enough (.80) to be acceptable for clinical use for substituted judgment. Their conclusion: Clinicians should recognize that their judgments of the utility of health states associated with localized prostate cancer may not correspond closely with those of the patient.

On the origins and development of evidence-based medicine and medical decision making

The aims of this paper are to identify the issues and forces that were the impetus for two recent developments in academic medicine, evidence-based medicine (EBM) and medical decision making (MDM); to make explicit their underlying similarities and differences; and to relate them to the fates of these innovations. Both developments respond to concerns about practice variation; the rapid growth of medical technology, leading to a proliferation of diagnostic and treatment options; the patient empowerment movement; and psychological research that raised questions about the quality of human judgment and decision making. Their commonalities include: use of Bayesian principles in diagnostic reasoning, and the common structure embedded in an answerable clinical question and a decision tree. Major differences include: emphasis on knowledge or judgment as the fundamental problem; the status of formal models and utility assessment; and the spirit and tone of the innovation. These differences have led to broader acceptance of EBM within academic medicine, while decision analysis, the fundamental tool of MDM, has been less welcomed in clinical circles and has found its place in guideline development, cost-effectiveness analysis, and health policy.

Inter-rater agreement in judging errors in diagnostic reasoning

CONTEXT AND OBJECTIVE

Inter-rater agreement is essential in rating clinical performance of doctors and other health professionals. The purpose of this study was to establish inter-rater agreement in categorising errors in the diagnostic process made by clinicians using computerised decision support systems.

METHODS

Eight possible error categories were developed for coding errors in diagnostic hypotheses and plans for next steps in the work-up. Two independent doctor judges rated 54 work-ups (representing 2 cases, each worked-up by 27 doctors). Inter-rater agreement between the 2 raters was computed using the kappa coefficient.

RESULTS

High inter-rater agreement was achieved in all categories except where the manual was not sufficiently specific and raters had to use their judgement. As is typical of the kappa coefficient, however, agreement corrected for chance fell markedly into the "poor" range when the percentages of expected and observed agreement were about the same.

CONCLUSION

Raters can achieve good agreement in categorising errors provided they are given explicit scoring rules and do not rely solely upon clinical judgement. The kappa coefficient has limitations in cases where the expected agreement between judges is high and variability is low. The use of 2 indices to assess agreement, analogous to test sensitivity and specificity, is recommended.

Ethnic Variation in Localized Prostate Cancer: A Pilot Study of Preferences, Optimism, and Quality of Life Among Black and White Veterans

Ethnic variations that may influence the preferences and outcomes associated with prostate cancer treatment are not well delineated. Our objective was to evaluate prospectively preferences, optimism, involvement in care, and quality of life (QOL) in black and white veterans newly diagnosed with localized prostate cancer. A total of 95 men who identified themselves as black/African-American or white who had newly diagnosed, localized prostate cancer completed a "time trade-off" task to assess utilities for current health and mild, moderate, and severe functional impairment; importance rankings for attributes associated with prostate cancer (eg, urinary function); and baseline and follow-up measures of optimism, involvement in care, and QOL. Interviews were scheduled before treatment, and at 3 and 12 months after treatment. At baseline, both blacks and whites ranked pain, bowel, and bladder function as their most important concerns. Optimism, involvement in care, and QOL were similar. Utilities for mild impairment were lower for blacks than whites, but were similar for moderate and severe problems. Decline in QOL at 3 and 12 months compared to baseline occurred for both groups. However, even with adjustment for marital status, education level, and treatment, blacks had less increase in nausea and vomiting and more increase in difficulty with sexual interest and weight gain compared with whites. Black and white veterans entered localized prostate cancer treatment with similar priorities, optimism, and involvement in care. Quality-of-life declines were common to both groups during the first year after diagnosis, but ethnic variation occurred with respect to nausea and vomiting, sexual interest, and weight gain.

Agreement between prostate cancer patients and their clinicians about utilities and attribute importance

PURPOSE

To examine the agreement between prostate cancer patients' utilities for selected health states and their rankings of the importance of six attributes of the health states and the clinicians' judgements of what would be in the patients' best interests.

METHOD

Patients with newly diagnosed localized prostate cancer individually completed a time trade-off utility assessment shortly after being diagnosed. The health states evaluated were constructed from a multi-attribute utility model that incorporated six aspects of living with the disease and outcomes of treatment. Each patient assessed his current health state and three hypothetical states that might occur in the future, and provided rankings of the importance of the six attributes. The clinicians caring for each patient independently provided their views of what utilities and importance rankings would be in the patient's best interest.

RESULTS

The across-participant correlations between patients' and clinicians' utilities were very low and not statistically significant. Across-participant correlations between patient and clinician importance rankings for the six attributes were also low. Across-health state and across-attribute correlations between utilities or importance rankings were highly variable across patient-clinician pairs.

CONCLUSION

In the clinical settings studied, there is not a strong relationship between valuations of current and possible future health states by patients with newly diagnosed prostate cancer and their clinicians. Implications of these results for substituted judgement, when clinicians advise their patients or recommend a treatment strategy, are discussed.

Critical thinking and clinical decision making in critical care nursing: a pilot study

OBJECTIVE

This pilot study examined the relationship of education level, years of critical care nursing experience, and critical thinking (CT) ability (skills and dispositions) to consistency in clinical decision making among critical care nurses. Consistency was defined as the degree to which intuitive and analytical decision processes resulted in similar selection of interventions in tasks of low and high complexity.

DESIGN

The study was nonexperimental and correlational.

SAMPLE

Critical care nurses (n = 54) from adult critical care units in 3 private teaching hospitals. The majority of nurses held a BSN or MSN and had an average of 9 years of direct clinical experience in the care of the critically ill.

RESULTS

Decision-making consistency decreased significantly between low-complexity and high-complexity tasks. Both intuitive and analytical decision processes produced clear intervention selections in the low-complexity task, although the analytical process resulted in a more complete specification of interventions. In the high-complexity task, however, only the intuitive process resulted in a clear, plausible, and safe specification of interventions. Education and experience were not related to CT ability, nor was CT ability related to decision-making consistency. Only greater years of critical care nursing experience increased the likelihood of decision-making consistency.

CONCLUSIONS

Overall, intuitive decision processes resulted in more clinically consistent selection of interventions across tasks. More investigation is needed to examine the influence of decision heuristics, and the conceptualization and measurement of CT abilities among practicing nurses.

Pilot Study of a Utilities-Based Treatment Decision Intervention for Prostate Cancer Patients

This pilot study evaluates a shared decision-making approach to individual decision making in localized prostate cancer care. The approach is based on a decision analytic model that incorporates patient utilities, ie, patient preferences among possible health states that might occur with prostate cancer treatments. Data on comorbidities, histologic grade of the biopsy, and age were obtained for 13 patients with newly diagnosed localized prostate cancer who received care in a Veterans Administration medical center. Using a standard gamble technique, interviewers obtained patient utilities for 5 distinct health states related to prostate cancer treatment. Utilities and patient clinical and pathologic characteristics were incorporated into the decision analytic model, and the derived quality-adjusted life expectancies were shared with the treating urologist before the first patient-physician discussion about treatment options. The results of the pilot study raised 2 major concerns. First, 4 patients had utility scores of 1.0 for all of the possible health states, and 7 patients had inconsistent utilities in which they rated both impotence and incontinence as a better health state than having just one of these problems. Second, the model recommended radiation therapy to individuals with a broad range of clinical characteristics, pathologic findings, and utility scores. Many of the patients who were recommended radiation therapy by the model received discordant recommendations from the treating urologist. Future refinements of both the utility assessment exercise and decision analytic model may be needed before the feasibility of the model in the clinical setting can be determined.

Presenting risks and benefits to patients

OBJECTIVE

To investigate whether patients are influenced by the order in which they learn the risks and benefits of a treatment and whether this effect is attenuated by a treatment's associated risk and/or benefit.

DESIGN

Subjects were randomized to review 1 of 6 medical treatment information brochures.

SETTING

Waiting rooms of primary care physicians at an academic health center.

PARTICIPANTS

Six hundred eighty-five subjects, ages 18 to 70 years.

INTERVENTION

Subjects reviewed 1 of 3 treatments for symptomatic carotid artery disease. The first (aspirin) was low-risk/low-benefit, the second (carotid endarterectomy surgery) was high-risk/high-benefit, and the third (extracranial-to-intracranial bypass surgery) was high-risk but of unknown benefit. Patients were also randomized to receive information about risk either before or after benefit. Patients were asked to rate the favorability of the treatment on a scale of 0 to 100 and whether they would consent. Finally, subjects rated how their decisions were influenced by the risk and benefit information.

MAIN RESULTS

Subjects evaluating aspirin therapy were influenced by the order of the risk/benefit information. Those learning about risks after benefits had a greater drop in their favorability ratings than subjects learning about risks before benefits (-10.9 vs -5.2 on a 100-point scale; P = .02) and were less likely to consent (odds ratio, 2.27; P = .04). In contrast, subjects evaluating carotid endarterectomy and extracranial-to-intracranial bypass were not influenced by information order. When subjects were influenced by the order of information, they also reported that the treatment's risk had less influence on their decision making (P < .01).

CONCLUSIONS

When patients evaluate low-risk medical interventions, they may form less favorable impressions of the treatment and be less likely to consent to the treatment when they learn about the risks after the benefits. Order effects were not observed with high-risk treatments regardless of potential benefits.

Physicians' judgments of survival after medical management and mortality risk reduction due to revascularization procedures for patients with coronary artery disease

STUDY OBJECTIVE

s: To assess the accuracy of physicians' judgments of survival probability for medically managed patients with coronary artery disease (CAD), and of the absolute risk reduction of mortality due to coronary artery bypass grafting (CABG) or percutaneous transluminal coronary angioplasty (PTCA) for such patients; and relationships among these judgments and the physicians' propensity to perform revascularization.

DESIGN

Two surveys (for three-vessel or two-vessel CAD) for patients presenting with stable CAD, currently managed medically, and without other life-limiting problems.

SETTING

Multiple educational conferences, 1996-1997.

PARTICIPANTS

Conference attendees.

MEASUREMENTS AND RESULTS

Main outcomes were proportions of patients for whom the physicians would recommend revascularization (CABG for three-vessel CAD, CABG or PTCA for two-vessel CAD), and judgments of the proportions of medically managed patients who would be alive after 5 years, 7 years, and 11 years, and of absolute risk reduction of mortality due to CABG (or PTCA for two-vessel CAD). At least one half of the participants judged the survival rate of medically managed patients with three-vessel or two-vessel CAD to be less than the lowest rates supported by the best available evidence. More than one fourth judged the absolute risk reduction due to CABG to be higher than the highest values based on such evidence. Physicians' propensity to perform revascularization correlated inversely with their judgments of survival given medical management, and with their judgments of absolute risk reduction due to revascularization.

CONCLUSIONS

Physicians may overuse revascularization because of excessive pessimism about survival of medically managed patients, and excessive optimism about the survival benefits of revascularization.

Improving continuing medical education for surgical techniques: applying the lessons learned in the first decade of minimal access surgery

OBJECTIVE

To examine the first decade of experience with minimal access surgery, with particular attention to issues of training surgeons already in practice, and to provide a set of recommendations to improve technical training for surgeons in practice.

SUMMARY BACKGROUND DATA

Concerns about the adequacy of training in new techniques for practicing surgeons began almost immediately after the introduction of laparoscopic cholecystectomy. The concern was restated throughout the following decade with seemingly little progress in addressing it.

METHODS

A preliminary search of the medical literature revealed no systematic review of continuing medical education for technical skills. The search was broadened to include educational, medical, and psychological databases in four general areas: surgical training curricula, continuing medical education, learning curve, and general motor skills theory.

RESULTS

The introduction and the evolution of minimal access surgery have helped to focus attention on technical skills training. The experience in the first decade has provided evidence that surgical skills training shares many characteristics with general motor skills training, thus suggesting several ways of improving continuing medical education in technical skills.

CONCLUSIONS

The educational effectiveness of the short-course type of continuing medical education currently offered for training in new surgical techniques should be established, or this type of training should be abandoned. At present, short courses offer a means of introducing technical innovation, and so recommendations for improving the educational effectiveness of the short-course format are offered. These recommendations are followed by suggestions for research.

Evidence-based morning report for inpatient pediatrics rotations

The authors describe a patient-centered method for teaching evidence-based medicine that is part of the inpatient morning report for pediatrics residents at the University of Illinois at Chicago. With library support, residents search for evidence to answer their own questions about patients, and present it at morning report

Cost-effectiveness of universal compared with voluntary screening for human immunodeficiency virus among pregnant women in Chicago

OBJECTIVES

To determine and compare the cost-effectiveness of implementing 3 screening strategies to detect human immunodeficiency virus (HIV) infection among pregnant women in Chicago, Illinois: no screening, voluntary screening, and universal screening.

METHODS

A decision-analysis model was developed, using standard cost-effectiveness analysis from a societal perspective. Reference case estimates were derived from a surveillance project conducted by the Illinois Department of Public Health and studies were published in the medical literature. Costs included direct and indirect medical costs associated with identification of pregnant women infected with HIV and identification, prevention, and treatment of perinatally HIV-infected newborns. Specifically, for each screening option, the cost per pregnant woman screened, the resulting number of pediatric HIV infections, and the number of newborn life-years were calculated. All costs were adjusted to the 1997 dollar value and discounted at 3%. Sensitivity analyses were determined for all variables included in the decision model.

RESULTS

The estimated prevalence of HIV infection among pregnant women in Chicago is .41%. For every 100,000 pregnant women, it is estimated that 104.6 children would be infected with HIV if no screening strategy were implemented and 44.8 children would be infected if voluntary HIV testing (assuming a 92.7% acceptance rate) were available. In comparison, if universal HIV testing was performed, the number of children infected with HIV would decrease to 40 cases. Sensitivity analysis across a maternal HIV prevalence rate of.01% to 2.2% found that universal screening would be cost-saving in communities where the seroprevalence is.21%. In Chicago, it would take an estimated 5. 2 months of screening pregnant women to avert 1 case of pediatric HIV. Taking into consideration the lifetime costs of treating a child with HIV infection, universal HIV testing of 100,000 pregnant women would result in a cost-savings of $3.69 million when compared with no screening, and $269,445 when compared with voluntary screening. We estimated that it would cost $11.1 million to screen 100,000 pregnant women in Chicago. The cost-savings produced with increased screening are the direct result of reduced cases of newborns infected with HIV. A 2-way sensitivity analysis was performed to examine how costs vary as a function of the voluntary rates for HIV-positive and HIV-negative women. When screening falls below 50% for HIV-positive mothers, universal screening becomes cheaper than voluntary screening even if no HIV-negative mothers were screened.

CONCLUSION

Reference case analyses showed that universal HIV screening of pregnant women in Chicago would both decrease the number of HIV-infected newborns and save money in comparison to voluntary or no testing strategies. Sensitivity analysis was robust across all variables for the conclusion that universal screening was more effective than voluntary screening. For many communities that have HIV prevalence rates for mothers of >.21%, universal screening would also save money in comparison to voluntary screening. For communities with prevalence rates <.21%, the benefits of universal screening may outweigh the costs for screening as we found that desirable incremental cost-effectiveness ratios were found for prevalence rates as low as.0075%.

Continuing medical education for life: eight principles

Continuing medical education (CME) is being pressured to change in response to increasing and changing educational needs of practicing physicians, fostered by technical innovations, evolution of practice styles, and the reorganization of health care delivery. Leadership in the reform of CME falls primarily to the medical specialty societies in light of their traditional responsibilities for accrediting CME and maintaining professional standards. To address the need for reform, the American College of Obstetricians and Gynecologists in 1997 organized a conference to assemble CME program administrators from several medical specialties and academicians with expertise in postgraduate learning. At the conference, issues facing CME were examined. The authors, who were conference participants, state and explain eight principles that emerged from conference discussions. (For example: "Educational activities should be supportive of and coordinated with the transition to evidence-based medicine.") The principles reflect the interspecialty and interdisciplinary consensus achieved by the conference participants and can serve as useful guideposts for educators as they work to improve CME in their institutions. The authors conclude by noting the need for a more systematic and rigorously analytic approach, where CME content is determined according to assessed needs and CME is evaluated by measuring outcomes; for this to happen, CME educators and faculty must be brought up to date through training, including the use of problem-based learning. CME must also instill collegiality, interaction, and collaboration into the learning environment instead of being a solitary learning activity. Finally, CME must not only emphasize the acquisition of knowledge but also instruct physicians in the process of decision making to help them better use their knowledge as they make clinical judgments.

Enhancement of clinicians' diagnostic reasoning by computer-based consultation: a multisite study of 2 systems

CONTEXT

Computer-based diagnostic decision support systems (DSSs) were developed to improve health care quality by providing accurate, useful, and timely diagnostic information to clinicians. However, most studies have emphasized the accuracy of the computer system alone, without placing clinicians in the role of direct users.

OBJECTIVE

To explore the extent to which consultations with DSSs improve clinicians' diagnostic hypotheses in a set of diagnostically challenging cases.

DESIGN

Partially randomized controlled trial conducted in a laboratory setting, using a prospective balanced experimental design in 1995-1998.

SETTING

Three academic medical centers, none of which were involved in the development of the DSSs.

PARTICIPANTS

A total of 216 physicians: 72 at each site, including 24 internal medicine faculty members, 24 senior residents, and 24 fourth-year medical students. One physician's data were lost to analysis.

INTERVENTION

Two DSSs, ILIAD (version 4.2) and Quick Medical Reference (QMR; version 3.7.1), were used by participants for diagnostic evaluation of a total of 36 cases based on actual patients. After training, each subject evaluated 9 of the 36 cases, first without and then using a DSS, and suggested an ordered list of diagnostic hypotheses after each evaluation.

MAIN OUTCOME MEASURE

Diagnostic accuracy, measured as the presence of the correct diagnosis on the hypothesis list and also using a derived diagnostic quality score, before and after consultation with the DSSs.

RESULTS

Correct diagnoses appeared in subjects' hypothesis lists for 39.5% of cases prior to consultation and 45.4% of cases after consultation. Subjects' mean diagnostic quality scores increased from 5.7 (95% confidence interval [CI], 5.5-5.9) to 6.1 (95% CI, 5.9-6.3) (effect size: Cohen d = 0.32; 95% CI, 0.23-0.41; P<.001). Larger increases (P = .048) were observed for students than for residents and faculty. Effect size varied significantly (P<.02) by DSS (Cohen d = 0.20; 95% CI, 0.08-0.32 for ILIAD vs Cohen d = 0.45; 95% CI, 0.31-0.59 for QMR).

CONCLUSIONS

Our study supports the idea that "hands-on" use of diagnostic DSSs can influence diagnostic reasoning of clinicians. The larger effect for students suggests a possible educational role for these systems.

Heuristics and biases: selected errors in clinical reasoning

Many clinical decisions are made in uncertainty. When the diagnosis is uncertain, the goal is to establish a diagnosis or to treat even if the diagnosis remains unknown. If the diagnosis is known (e.g., breast cancer or prostate cancer) but the treatment is risky and its outcome uncertain, still a choice must be made. In researching the psychology of clinical judgment and decision making, the major strategy is to compare observed clinical judgments and decisions with the normative model established by statistical decision theory. In this framework, the process of diagnosing is conceptualized as using imperfect information to revise opinions; Bayes' theorem is the formal rule for updating a diagnosis as new data are available. Treatment decisions should be made so as to maximize expected value. This essay uses Bayes' theorem and concepts from decision theory to describe and explain some well-documented errors in clinical reasoning. Heuristics and biases are the cognitive factors that produce these errors.

Framing effects in choices between multioutcome life-expectancy lotteries

AIM

To explore framing or editing effects and a method to debias framing in a clinical context.

METHOD

Clinical scenarios using multioutcome life-expectancy lotteries of equal value required choices between two supplementary drugs that either prolonged or shortened life from the 20-year beneficial effect of a baseline drug. The effects of these supplementary drugs were presented in two conditions, using a between-subjects design. In segregated editing (n = 116) the effects were presented separately from the effects of the baseline drug. In integrated editing (n = 100), effects of supplementary and baseline drugs were combined in the lottery presentation. Each subject responded to 30 problems. To explore one method of debiasing, another 100 subjects made choices after viewing both segregated and integrated editings of 20 problems (dual framing).

RESULTS

Statistically significant preference reversals between segregated and integrated editing of pure lotteries occurred only when one framing placed outcomes in the gain domain, and the other framing placed them in the loss domain. When both editings resulted in gain-domain outcomes only, there was no framing effect. There was a related relationship of framing-effect shifts from losses to gains in mixed-lottery-choice problems. Responses to the dual framing condition did not consistently coincide with responses to either single framing. In some situations, dual framing eliminated or lessened framing effects.

CONCLUSION

The results support two components of prospect theory, coding outcomes as gains or losses from a reference point, and an s-shaped utility function (concave in gain, convex in loss domains). Presenting both alternative editings of a complex situation prior to choice more fully informs the decision maker and may help to reduce framing effects. Given the extent to which preferences shift in response to alternative presentations, it is unclear which choice represents the subject's "true preferences."

QOL and outcomes research in prostate cancer patients with low socioeconomic status

The VA Cancer of the Prostate Outcomes Study (VA CaPOS) is collecting quality-of-life (QOL) information from prostate cancer patients, spouses, and physicians at six VA medical centers. Currently, 601 men with prostate cancer are included in the study, most of whom are of low socioeconomic status and over half of whom are African-American. Quality-of-life responses were most favorable for newly diagnosed patients, intermediate for those with stable metastatic disease, and poorest for those with progressive metastatic disease. Patients could not provide reliable estimates of their own preferences for future QOL states but responded reliably to questions phrased as a comparison of the preferences of two hypothetical patients. High out-of-pocket costs for hormonal therapies, lack of health insurance, and a belief that the non-VA system offered poorer services were the most common reasons for patient transferral to the VA system. Satisfaction with medical care was generally high. While African-American patients were more likely to have advanced prostate cancer at diagnosis, after adjustment for differences in health literacy, race was no longer a significant predictor of advanced disease. The VA CaPOS provides useful information on health status and patient satisfaction of VA prostate cancer patients. Long-term evaluations are needed to detect clinically meaningful QOL information as the disease progresses.

A multi-attribute model of prostate cancer patient's preferences for health states

Multi-attribute utility theory (MAUT) provides a way to model decisions involving trade-offs among different aspects or goals of a problem. We used MAUT to model prostate cancer patients' preferences for their own health state and we compared this model to patients' global judgments of health state utility. 57 patients with prostate cancer (mean age = 70) at two Chicago Veterans Administration health clinics were asked to evaluate health states described in terms of five health attributes affected by prostate cancer: pain, mood, sexual function, bladder and bowel function, and fatigue and energy. Each attribute had three levels that were used to form three clinically realistic health state descriptions (A = high, B = moderate, C = low). A fourth personalized health description (P) matched the patient's current health. We first measured patients' preferences using time trade-off (TTO) judgments for the three health states (A, B, and C) and for their own current health state (P). The TTO for the patient's own health state (P) was standardized by comparing it to TTO judgments for states A and C. We next constructed a multi-attribute model using the relative importance of the five attributes. The MAU scores were moderately correlated with the TTO preference judgments for the personalized state (Pearson r = 0.38, N = 57, p < 0.01). Thus, patients' preference judgments are moderately consistent and systematic. MAUT appears to be a potentially feasible method for evaluating preferences of prostate cancer patients and may prove helpful in assisting with patient decision making.

Effects of prognosis, perceived benefit, and decision style on decision making and critical care on decision making in critical care

OBJECTIVE

To assess the effects of prognostic estimates, perceived benefit of treatment, and practice style on decision-making in critical care.

DESIGN

Randomized assignment of subjects to either of two versions of a questionnaire designed to elicit treatment decisions for six intensive care unit cases based on actual patients. One version offered optimistic survival forecasts; the other, pessimistic forecasts.

SUBJECTS

A random sample of 120 clinicians obtained from the Canadian Critical Care Society was contacted by mail. One version of the questionnaire was randomly assigned and mailed to each. Thirty-four replies, 17 for each version (response rate, 28%), were received and analyzed.

MEASUREMENTS AND MAIN RESULTS

A list of treatment/management options was developed for each case, in three categories: recommended, questionable, and unacceptable. Subjects were also able to list new options that they would order that were not on the list. The dependent variables were the number of actions ordered in each category and the total for each case. Perceived benefit was measured by comparing subjective estimates of the probability of survival with the optimistic/pessimistic forecast given in the case. Practice style was assessed by correlating the total number of actions ordered across all possible pairs of cases. There were no significant differences between the two questionnaires on actions ordered either by category or by amount per category. Perceived benefit did not appear to be an important factor in decision-making. However, statistically significant correlations provide evidence for practice style in intensive care unit decision-making on an interventionist/noninterventionist dimension.

CONCLUSIONS

There is no evidence that erroneous or biased prognostic estimates affect intensive care unit treatment choices. Neither the principle of maximizing expected utility nor the Rule of Rescue appear to affect these decisions systematically, but practice style does.

Prostate cancer patients' utilities for health states: how it looks depends on where you stand

Two versions of the time-tradeoff (TTO) method were compared. In the personal TTO version, 31 prostate cancer patients decided whether they personally would give up some longevity to have perfect health rather than a longer life in a state of poor health associated with prostate cancer. In the impersonal version, 28 patients compared two hypothetical friends, one of whom has perfect health but will live less time than the other who is in poor health, and decided which person they would rather be. All patients evaluated three hypothetical health states. The two TTO methods were assessed by examining 1) how well they distinguished three health states of varying degrees of dysfunction and 2) patients' willingness to trade time for quality of life. Patients using the impersonal TTO version were more likely than those using the personal version to order the three health states appropriately (68% vs 16%, p < 0.0001) and were more willing to trade off length of life for quality of life (p < 0.05).

A comparison of perspectives on prostate cancer: analysis of utility assessments of patients and physicians

BACKGROUND

Quality-of-life considerations are important in metastatic prostate cancer. In this study, we interviewed physicians and patients about their assessments and expectations on quality of life as metastatic prostate cancer progresses.

METHODS

Physicians and patients made utility assessments of three hypothetical health states for metastatic disease using the time trade-off technique. Scores were bounded on a scale from 0.0 (death) to 1.0 (perfect health).

RESULTS

Patients rated each of the health states as less desirable than the physicians.

CONCLUSIONS

Physicians and patients differ in their perspectives on expected quality of life with metastatic prostate cancer. Our results emphasize the need to assess patients' utilities directly.

Changes in diagnostic decision-making after a computerized decision support consultation based on perceptions of need and helpfulness: a preliminary report

We examined the degree to which attending physicians, residents, and medical students' stated desire for a consultation on difficult-to-diagnose patient cases is related to changes in their diagnostic judgments after a computer consultation, and whether, in fact, their perceptions of the usefulness of these consultations are related to these changes. The decision support system (DSS) used in this study was ILIAD (v4.2). Preliminary findings based on 16 subjects' (6 general internists, 4 second-year residents in internal medicine, and 6 fourth-year medical students) workup of 136 patient cases indicated no significant main effects for 1) level of experience, 2) whether or not subjects indicated they would seek a diagnostic consultation before using the DSS, or 3) whether or not they found the DSS consultation in fact to be helpful in arriving at a diagnosis (p > .49 in all instances). Nor were there any significant interactions. Findings were similar using subjects or cases as the unit of analysis. It is possible that what may appear to be counter-intuitive, and perhaps irrational, may not necessarily be so. We are currently examining potential explanatory hypotheses in our ongoing current, larger study.

The influence of a decision support system on the differential diagnosis of medical practitioners at three levels of training

As computer-based diagnostic consultation systems become, available, their influence and usefulness need to be evaluated. This report, based on partial data from a larger study, examines the influence of Iliad, a diagnostic consultation system, on the differential diagnosis of fourth year medical students, residents in medicine, and attendings in general internal medicine. Our results show that when faced with difficult diagnostic cases, medical students add significantly more diagnoses from Iliad's differential than do residents or attendings. However, the quality of Iliad's diagnostic advice in terms of the presence of the correct diagnosis, is no better for consultations done by students or residents compared to attendings.

Effects of a decision support system on the diagnostic accuracy of users: a preliminary report

OBJECTIVES

To assess the effects of incomplete data upon the output of a computerized diagnostic decision support system (DSS), to assess the effects of using the system upon the diagnostic opinions of users, and to explore if these effects vary as a function of clinical experience.

DESIGN

Experimental pilot study. Four clusters of nine cases each were constructed and equated for case difficulty. Definitive findings were omitted from the case abstracts. Subjects were randomly assigned to one of four clusters and were trained on the DSS prior to use.

SUBJECTS

The study involved 16 physicians at three levels of clinical experience (six general internists, four residents in internal medicine, and six fourth-year medical students), from three academic medical centers.

PROCEDURE

Each subject worked up nine cases, first without and then with ILIAD consultation. They were asked to offer up to six potential diagnoses and to list up to three steps that should be the next items in the diagnostic workup. Effects of DSS consultation were measured by changes in the position of the correct diagnosis in the lists of differential diagnoses, pre- and post-consultation.

RESULTS

The DSS lists of diagnostic possibilities contained the correct diagnosis in 38% of cases, about midway between the levels of accuracy of residents and attending general internists. In over 70% of cases, the DSS output had no effect on the position of the correct diagnosis in the subjects' lists. The system's diagnostic accuracy was unaffected by the clinical experience of the users.