Understanding decision-making in cardiac imaging: determinants of appropriate use

Abstract

Factors that influenced the ordering of echocardiograms by clinicians at a tertiary care hospital did not appear to be amenable to control with AUC. Alternative approaches may be more effective than the AUC in addressing the overuse of echocardiography.

Why do clinicians overtest? A narrative review and workshop group discussion exploring influences on clinician overtesting as possible causes of overdiagnosis

“…"I'm often a bit defensive...I guess that's partly that legal thing" [38] "I think the whole medical-legal thing also makes people more inclined to CT [computed tomography] someone even if they have a pretty low suspicion just 'cause no one wants to be sued" [39] "I think litigation is a problem; you miss one neck... fracture or bleed in the brain you are going to court" [47] Factor Articles Illustrative quotes Clinician knowledge and understanding 25 articles [2,3,5,15,29,32,33,35,37-39,42−44,47,52,53,59−66] "How much work [laboratory testing] is, how much it costs, how much normal results can uctuate, things like that, I think we know very little about that" [3] "Nothing can really go wrong [with overutilization]" [3] "You understand the natural course of disease and the point in time at which you have to make a decision to do something different" [29] "When I'm admitting a patient or doing clinical work, it's kind of affected my thought process to where I think a little bit more about 'do I really need to get this test? ', 'will it really change management?…”

“…Need to explain the limitation of check-ups" [ "Lab testing is often only done for the doctor's peace of mind." [3] "I am worried if they don't have a full assessment and I miss something that it is going on with their heart that is not apparent because ECGs [electrocardiograms] and clinical examinations are not very precise" [29] "You're sitting there with someone who has a sudden-onset splitting headache, but otherwise you see nothing alarming… A CT scan for an acute headache. Even if the pre-test chance is 0.01.…”

“…How would you know it won't affect them?" [38] "You have to be self-con dent in not doing something" [43] Cognitive biases and experiences 12 articles [10,15,[28][29][30][36][37][38][39][40]46,69] "'There might be a bias to a situation where some doctors missed an important nding, when they were a junior doctor, so they always do scans because they are worried that something might happen like years ago" [29] "If you've ever experienced something like that, you can be sure that you'll send patients with vague complaints for further testing much faster. Absolutely" [37] "It's certainly a-hard to be, treating dying people who are young and not to worry about all of this and I, but I try not to change my practice based on my own personal experience of one or two people dying of prostate cancer" [38] "I would say that my clinical experience highly in-uences my ordering… sometimes I feel a certain way about a patient even though they don't t a certain pro le and I'll end up doing something additional for them" [39] " "Some GPs mentioned their frustration at not being able to offer the patient something useful, at the feeling of empty hands, owing to the lack of a diagnostic or therapeutic plan for patients presenting with unexplained complaints.…”

“…We have to diagnose them if they have a problem" [38] "If it's on your radar… you're almost honorbound to do the study of choice" [39] "My personal policy I would always disclose...generally speaking I would always explain the diagnosis" [42] "'Action' dogma of doing anything possible for the individual patient" [43] "It can reduce the anxiety and prevent representations to the hospital, helping to keep them from coming in with chest pains" [29] "Now she had problems with her feet and arms, morning stiffness, pain in the joints. But there was no redness, no swelling, wasn't warm, functioning was good.…”

Qualitative study of cardiologists’ perceptions of factors influencing clinical practice decisions

“…In a qualitative study addressing the determinants of appropriate use of echocardiography, Fonseca and colleagues22 found that physician factors including training, experience, handling uncertainty and perception of peer and patient expectations influenced echocardiogram use. Similarly, Hisham and colleagues23 found that despite having positive attitudes about evidence and CPGs, doctors’ practice was often not evidence-based due to barriers including heavy workload and workplace culture.…”