Physician uncertainty aversion impacts medical decision making for older patients with acute myeloid leukemia: results of a national survey

Abstract

Elderly patients with acute myeloid leukemia can be treated with intensive chemotherapy, low-intensity therapy such as low-dose aracytine or hypomethylating agents, or best supportive care. The choice between these treatments is a function of many patient-related and disease-related factors. We investigated how physicians’ behavioral characteristics affect medical decision-making between intensive and non-intensive therapy in this setting. A nationwide cross-sectional online survey of hematologists collected data on medical decision-making for 6 clinical vignettes involving older acute myeloid leukemia patients that were representative of routine practice. Questionnaires elicited physicians’ demographic and occupational characteristics along with their individual behavioral characteristics according to a decision theory framework. From the pattern of responses to the vignettes, a K-means clustering algorithm was used to distinguish those who were likely to prescribe more intensive therapy and those who were likely to prescribe less intensive or no therapy. Multivariate analyses were used to identify physician’s characteristics predictive of medical decision-making. We obtained 230 assessable answers, which represented an adjusted response rate of 45.4%. A multivariate model (n=210) revealed that physicians averse to uncertainty recommend significantly more intensive chemotherapy: Odds Ratio (OR) [95% Confidence Interval (CI)]: 1.15 [1.01;1.30]; P=0.039. Male physicians who do not conform to the expected utility model (assumed as economically irrational) recommend more intensive chemotherapy [OR (95% CI) = 3.45 (1.34; 8.85); P=0.01]. Patient volume per physician also correlated with therapy intensity [OR (95% CI)=0.98 (0.96; 0.99); P=0.032]. The physicians’ medical decision-making was not affected by their age, years of experience, or hospital facility. The significant association between medical decision and individual behavioral characteristics of the physician identifies a novel non-biological factor that may affect acute myeloid leukemia patients’ outcomes and explain variations in clinical practice. It should also encourage the use of validated predictive models and the description of novel bio-markers to best select patients for intensive chemotherapy or low-intensity therapy.

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“… Bernardes et al, 2013 [ 55 ] Whether physician sex moderates the effects of patient (distressed) pain behaviours and diagnostic evidence of pathology on treatment prescriptions and referrals; explore the mediating role of pain credibility judgments and psychological attributions on these effects Portugal Primary care Physician Referral, prescription, assessment Gender Physician sex, clinical cues (evidence of pathology, distress) Chronic lower back pain Confirming the hypothesis, physician sex moderates the influence of clinical cues on pain management practices: evidence of pathology had a larger effect on male than on female physicians’ referrals to psychology/psychiatry. Bories et al, 2018 [ 56 ] To test the hypothesis that physician uncertainty aversion impacts medical decision making for older patients with acute myeloid leukaemia France Acute Physician Prescription Age (note clinically relevant) Physician demographic, occupational, behavioural characteristics Acute myeloid leukaemia Physician attitudes to risk influenced chemotherapy decisions for older patients. Physicians opting for intensive chemotherapy (IC) had higher aversion to uncertainty and treated fewer patients annually, than the low IC group but were similar in age, hierarchical status or years of experience.…”