Pseudodoxia Pediatrica

Bakwin, Harry

doi:10.1056/nejm194506142322401

Cited by 57 publications

(23 citation statements)

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“…Their perceived base rate of patients needing antibiotics may have influenced their likelihood of recommending antibiotics independently of their perception of the weight of any given clinical factor. This expectation bias across different specialties was demonstrated many years ago in a study of children being evaluated for tonsillectomy where physician characteristics rather than patient characteristics determined whether or not tonsillectomy was recommended by them [22].…”

Section: Discussionmentioning

confidence: 99%

Factors Affecting Antibiotic Prescribing for Acute Respiratory Infection by Emergency Physicians

Safdar¹,

Tape²,

Fox³

et al. 2014

Health

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Background: Antibiotics are frequently prescribed for upper acute respiratory tract infections (ARI) in the emergency department. To reduce inappropriate overprescribing, it is necessary to understand factors influencing physicians' decisions to prescribe antibiotics. Objective: Analyze the judgment policies of emergency physicians to determine factors predicting antibiotic use. Design: Paper case vignette study. Participants: 104 emergency physicians from Wisconsin. Measurements: We used judgment analysis to derive the policies of 104 emergency physicians from their responses to 20 case vignettes. We designed the cases such that each physician's use of clinical findings and patient factors could be inferred from the decisions they made about each case. Findings were compared to primary care practitioners (PCPs) in Colorado responding to the same paper cases to examine differences in factors influencing prescribing among the two groups. Results: The emergency physicians said they would prescribe an antibiotic (yes/no) in 51.4% of cases compared with 44.5% in the Colorado study. The majority of emergency physicians gave the greatest weight to duration of illness (51%), followed by temperature (20%) and cough (12%). Conclusions: These emergency physicians prescribed antibiotics more frequently than the Colorado PCPs. There was little difference in how clinical findings were weighted, suggesting this was not the source of the higher prescription rate among the emergency physicians. The considerable emphasis on duration of illness suggests that this would be a productive area for educational efforts to reduce antibiotic prescribing for ARI in the emergency department.

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Section: Discussionmentioning

confidence: 99%

Factors Affecting Antibiotic Prescribing for Acute Respiratory Infection by Emergency Physicians

Safdar¹,

Tape²,

Fox³

et al. 2014

Health

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“…18 In the same decade, a study in the USA (published in the 1940s) found minimal agreement among physicians in judging which children would benefit from tonsillectomy. 42 These initial doubts belatedly led to dramatic declines in tonsillectomy rates on both sides of the Atlantic 43 and RCTs to better define the small subgroup of children where tonsillectomy is effective. 44 The interpretation of observed geographical variation in routine data is not straightforward.…”

Section: Introductionmentioning

confidence: 99%

Using clinical practice variations as a method for commissioners and clinicians to identify and prioritise opportunities for disinvestment in health care: a cross-sectional study, systematic reviews and qualitative study

Hollingworth

Rooshenas

Busby

et al. 2015

Health Services and Delivery Research

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BackgroundNHS expenditure has stagnated since the economic crisis of 2007, resulting in financial pressures. One response is for policy-makers to regulate use of existing health-care technologies and disinvest from inefficiently used health technologies. A key challenge to disinvestment is to identify existing health technologies with uncertain cost-effectiveness.ObjectivesWe aimed to explore if geographical variation in procedure rates is a marker of clinical uncertainty and might be used by local commissioners to identify procedures that are potential candidates for disinvestment. We also explore obstacles and solutions to local commissioners achieving disinvestment, and patient and clinician perspectives on regulating access to procedures.MethodsWe used Hospital Episode Statistics to measure geographical variation in procedure rates from 2007/8 to 2011/12. Expected procedure numbers for each primary care trust (PCT) were calculated adjusting for proxies of need. Random effects Poisson regression quantified the residual inter-PCT procedure rate variability. We benchmarked local procedure rates in two PCTs against national rates. We conducted rapid systematic reviews of two high-use procedures selected by the PCTs [carpal tunnel release (CTR) and laser capsulotomy], searching bibliographical databases to identify systematic reviews and randomised controlled trials (RCTs). We conducted non-participant overt observations of commissioning meetings and semistructured interviews with stakeholders about disinvestment in general and with clinicians and patients about one disinvestment case study. Transcripts were analysed thematically using constant comparison methods derived from grounded theory.ResultsThere was large inter-PCT variability in procedure rates for many common NHS procedures. Variation in procedure rates was highest where the diffusion or discontinuance was rapidly evolving and where substitute procedures were available, suggesting that variation is a proxy for clinical uncertainty about appropriate use. In both PCTs we identified procedures where high local use might represent an opportunity for disinvestment. However, there were barriers to achieving disinvestment in both procedure case studies. RCTs comparing CTR with conservative care indicated that surgery was clinically effective and cost-effective on average but provided limited evidence on patient subgroups to inform commissioning criteria and achieve savings. We found no RCTs of laser capsulotomy. The apparently high rate of capsulotomy was probably due to the coding inaccuracy; some savings might be achieved by greater use of outpatient procedures. Commissioning meetings were dominated by new funding requests. Benchmarking did not appear to be routinely carried out because of capacity issues and concerns about data reliability. Perceived barriers to disinvestment included lack of collaboration, central support and tools for disinvestment. Clinicians felt threshold criteria had little impact on their practice and that prior approval systems would not be cost-effective. Most patients were unaware of rationing.ConclusionsPolicy-makers could use geographical variation as a starting point to identify procedures where health technology reassessment or RCTs might be needed to inform policy. Commissioners can use benchmarking to identify procedures with high local use, possibly indicating overtreatment. However, coding inconsistency and limited evidence are major barriers to achieving disinvestment through benchmarking. Increased central support for commissioners to tackle disinvestment is needed, including tools, accurate data and relevant evidence. Early engagement with patients and clinicians is essential for successful local disinvestment.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

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“…The imperfections of clinical reasoning in modern medicine were written about more than 60 years ago, 6 but it is only quite recently that the problem has come into focus. Perhaps it is not altogether surprising that it has taken so long for the problem to attract the attention it deserves.…”

Section: Introductionmentioning

confidence: 99%

Better clinical decision making and reducing diagnostic error

Croskerry

Nimmo²

2011

J R Coll Physicians Edinb

121

131

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A major amount of our time working in clinical practice involves thinking and decision making. Perhaps it is because decision making is such a commonplace activity that it is assumed we can all make effective decisions. However, this is not the case and the example of diagnostic error supports this assertion. Until quite recently there has been a general nihilism about the ability to change the way that we think, but it is now becoming accepted that if we can think about, and understand, our thinking processes we can improve our decision making, including diagnosis. In this paper we review the dual process model of decision making and highlight ways in which decision making can be improved through the application of this model to our day-to-day practice and by the adoption of de-biasing strategies and critical thinking.

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Pseudodoxia Pediatrica

Cited by 57 publications

References 0 publications

Factors Affecting Antibiotic Prescribing for Acute Respiratory Infection by Emergency Physicians

Factors Affecting Antibiotic Prescribing for Acute Respiratory Infection by Emergency Physicians

Using clinical practice variations as a method for commissioners and clinicians to identify and prioritise opportunities for disinvestment in health care: a cross-sectional study, systematic reviews and qualitative study

Better clinical decision making and reducing diagnostic error

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