The time paradox of emergency medicine: Another inverted U curve

Fatovich, Daniel M

doi:10.1111/1742-6723.12847

Cited by 3 publications

(4 citation statements)

References 17 publications

(27 reference statements)

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“…Previous proposals that more extreme clinician sensitivity may determine adverse patient outcomes were qualitative. [16,36,45] The present findings provide a means to quantify the importance of these a priori principles.…”

Section: Discussionmentioning

confidence: 81%

“…(2) Clinician sensitivity/bias in rating the HoNOS is only important if it reflects clinician factors that cause patient outcomes. [16,36,37] The fact that the study’s measures of clinician sensitivity/bias preceded changes in outcomes allows the possibility of causality. However, the causal mechanisms are unclear, because most clinicians were Community Mental Health Nurses (CMHNs), who did not make diagnoses, prescribe medication or hold admission rights.…”

Section: Discussionmentioning

confidence: 99%

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Clinicians’ ratings of the Health of the Nation Outcome Scales (HoNOS) show sensitivity/bias that may affect patients’ progress: analyses of routine administrative data

Williams

2020

Preprint

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Objectives(1) To estimate clinician sensitivity/bias in rating the HoNOS. (2) To test if high or low clinician sensitivity determines slower resolution of patients’ problems or earlier inpatient admission.DesignThe primary analysis used many-facet Item Response Theory to construct a multi-level Graded Response Model that teased apart clinician sensitivity/bias from the severity of patients’ problems in routine HoNOS records. Secondary analyses then tested if patients’ outcomes depend on their clinicians’ sensitivity/bias.Outcome measuresThe outcome measures were (1) overall differences in sensitivity/bias between (a) individual clinicians and (b) different Community Mental Health Teams (CMHTs); (2) clinical outcomes, comprising (a) the rate of resolution of patients’ problems and (b) the dependence of the time to inpatient admission on clinician sensitivity/bias.SettingAll archival electronic HoNOS records for all new referrals to all CMHTs providing mental health services in secondary care in a New Zealand District Health Board during 2007-2015.ParticipantsThe initial sample comprised 2170 adults of working age who received 5459 HoNOS assessments from 186 clinicians. From these initial data, I derived an opportunistic, connected, bipartite, longitudinal network, in which (i) every patient received HoNOS ratings from 2 or more clinicians and (ii) every clinician assessed more than 5 patients. The bipartite network comprised 88 clinicians and 778 patients; 112 patients underwent later inpatient admission.ResultsSensitivity/bias differed importantly between individual clinicians and CMHTs. Patients whose clinicians had more extreme sensitivity/bias showed slower resolution of their problems and earlier inpatient admission.ConclusionsRaw HoNOS ratings reflect the sensitivity/bias of clinicians almost as much as the severity of patients’ problems. Additionally, low or high clinician sensitivity can adversely affect patients’ outcomes. Hence, the HoNOS’s main value may be to measure clinician sensitivity. Accounting for clinician sensitivity could enable the HoNOS to fulfil its goal of improving mental health services.Strengths and limitations of the studyThe study derived a connected network of clinicians and patients that approximates a rational design for estimating clinicians’ sensitivity/bias.The opportunistic network sample was atypical, with chronic patients and experienced clinicians – so the study may under-estimate clinician bias.The study’s statistical methods were appropriate to the ordinal nature of HoNOS ratings.The study used earlier estimates of clinician sensitivity/bias to predict later outcomes – so that effects of clinician sensitivity/bias on outcomes may be causalThe study assumed that all HoNOS items tap a single dimension of the severity of patients’ problems.

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Section: Discussionmentioning

confidence: 81%

Section: Discussionmentioning

confidence: 99%

Clinicians’ ratings of the Health of the Nation Outcome Scales (HoNOS) show sensitivity/bias that may affect patients’ progress: analyses of routine administrative data

Williams

2020

Preprint

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“…Very few situations in medicine require immediate action. 1 Patients with a more severe spectrum of disease are more likely to benefit from treatment, as beautifully illustrated in the book Overdiagnosed. 2 Every action although has potential harms, which need to be weighed against the potential benefits.…”

Section: Outline Of the Problemmentioning

confidence: 99%

“…Very few situations in medicine require immediate action . Patients with a more severe spectrum of disease are more likely to benefit from treatment, as beautifully illustrated in the book Overdiagnosed.…”

Section: Outline Of the Problemmentioning

confidence: 99%

Don't just do something, stand there! The value and art of deliberate clinical inertia

Keijzers

Cullen

Egerton-Warburton

et al. 2018

Emerg Medicine Australasia

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It can be difficult to avoid unnecessary investigations and treatments, which are a form of low-value care. Yet every intervention in medicine has potential harms, which may outweigh the potential benefits. Deliberate clinical inertia is the art of doing nothing as a positive response. This paper provides suggestions on how to incorporate deliberate clinical inertia into our daily clinical practice, and gives an overview of current initiatives such as 'Choosing Wisely' and the 'Right Care Alliance'. The decision to 'do nothing' can be complex due to competing factors, and barriers to implementation are highlighted. Several strategies to promote deliberate clinical inertia are outlined, with an emphasis on shared decision-making. Preventing medical harm must become one of the pillars of modern health care and the art of not intervening, that is, deliberate clinical inertia, can be a novel patient-centred quality indicator to promote harm reduction.

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Longer Prehospital Time was not Associated with Mortality in Major Trauma: A Retrospective Cohort Study

Brown¹,

Tohira²,

Bailey³

et al. 2019

Prehospital Emergency Care

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The time paradox of emergency medicine: Another inverted U curve

Cited by 3 publications

References 17 publications

Clinicians’ ratings of the Health of the Nation Outcome Scales (HoNOS) show sensitivity/bias that may affect patients’ progress: analyses of routine administrative data

Clinicians’ ratings of the Health of the Nation Outcome Scales (HoNOS) show sensitivity/bias that may affect patients’ progress: analyses of routine administrative data

Don't just do something, stand there! The value and art of deliberate clinical inertia

Longer Prehospital Time was not Associated with Mortality in Major Trauma: A Retrospective Cohort Study

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