Is there sex bias in the management of coronary artery disease?
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Coronary Disease↗
Biomedical subjects
R M Poses
Publications and source records attributed to R M Poses.
Controlled trial using computerized feedback to improve physicians' diagnostic judgments.
The goal of this study was to test an innovative method to improve physicians' diagnostic judgments by integrating the use of a computer program (employing cognitive feedback to teach a clinical rule that predicts the probability of streptococcal pharyngitis), a traditional lecture, and periodic disease-prevalence reports. In a controlled trial using pre- and postintervention measures involving 885 patients, the authors compared the effects of the integrated method on the diagnostic judgments of seven experienced physicians at a university health service (from 1982 to 1985) with the effects of the lecture alone on the judgments of seven experienced physicians at a different university health service (1986 to 1987). The integrated method significantly improved the quality of the physicians' judgments as measured by calibration curves and Brier scores, and increased the level of agreement between the physicians' judgments and those made by the clinical prediction rule. The lecture alone produced less improvement in the quality of the physicians' judgments, and decreased the level of agreement with the rule. The authors conclude that this method, based on cognitive psychology, is a promising educational tool.
Computer-Assisted Instruction↗
Ego bias, reverse ego bias, and physicians' prognostic.
OBJECTIVE: To evaluate the effects of "ego bias" on physicians' prognostic judgments. Ego bias is defined as systematic overestimation of the prognosis of one's own patients compared with the expected outcome of a population of similar patients. DESIGN: A prospective study of an inception cohort of critically ill patients followed until death or discharge from the hospital. PATIENTS: Consecutive patients admitted to either an ICU or an intermediate ICU at a teaching hospital during January and February 1987, excluding patients admitted after coronary artery bypass grafting, for elective dialysis, or transferred to the intermediate ICU from another critical care unit. MAIN OUTCOME MEASURES AND COMPARISONS: House officers' and critical care attending physicians' assessments of the likelihood of inhospital survival for each patient, and their assessments of the overall survival rate of ICU and intermediate ICU patients were compared with each other and with actual survival rates. RESULTS: The attending physicians' predictions for individual patients were significantly lower than their judgments of the overall survival rate, 79.8% vs. 88.0%, p = .0067, suggesting the presence of a "reverse ego bias." The house officers' predictions for individual patients were significantly higher than their judgments of the overall survival rate, 73.5% vs. 68.9%, p = .018, suggesting the presence of ego bias. The magnitude and directions of these differences varied significantly among the attending physicians (F = 4.3, degrees of freedom = 3, p = .0062 by repeated-measures analysis of variance) and the house officers (F = 6.3, degrees of freedom = 5, p = .0001). CONCLUSIONS: The critical care attending physicians exhibited reverse ego bias that was mainly a function of their optimism about the overall survival rate for critically ill patients. The house officers exhibited ego bias that was mainly a function of their pessimism about the overall survival rate for critically ill patients.
Attitude of Health Personnel↗
Does hypogonadism contribute to the occurrence of a minimal trauma hip fracture in elderly men?
The risk of MTHF in hypogonadal elderly men was investigated with a case-control model. Cases and controls were selected from males age 65 years and older residing in the 120-bed McGuire Veterans Affairs Medical Center Nursing Home Care Unit over a 5-day interval. Historical data and serum free testosterone (fTe) were available on 17 subjects with MTHF and 61 controls. When groups were compared for differences in age, race, alcohol abuse, cigarette abuse, and diseases or drugs that may be associated with MTHF, only race was significantly different. Although 25.6% of residents were black, 100% of MTHF subjects were white (P = 0.004). Hypogonadism was defined as a random fTe less than 9 pg/mL (normal 9 to 46 pg/mL) and was found in 21 subjects (26.9%). Of cases with a MTHF, 58.8% were hypogonadal compared with only 18.0% of controls. Utilizing logistic regression, a highly significant association was found between hypogonadism and MTHF (P = 0.008), and using the odds ratio, subjects with hypogonadism were 6.5 times more likely to have a MTHF (95% CI 2.0 to 20.6). To adjust for race, the odds ratio was repeated excluding black subjects, and the results remained highly significant (4.6, 95% CI 1.3 to 16.2). We conclude that hypogonadal elderly white men may be at increased risk for MTHF.
Black or African American↗
Derivation and validation of a clinical diagnostic model for chlamydial cervical infection in university women.
We developed and prospectively tested a logistic regression model for chlamydial cervical infection. Study subjects included 2271 women receiving gynecologic care in our student health clinic. Clinical data were collected in a standardized fashion. We identified cell culture--isolated Chlamydia trachomatis from 133 (9%) of 1458 subjects in the derivation set and 73 (10%) of 729 subjects in the validation set. Model variables included a new sexual partner within 2 months or more than one sexual partner within 6 months; cervical ectopy; cervical friability; at least 20 polymorphonuclear leukocytes per high-power field in cervical secretions; white blood cells in vaginal secretions; and use of an antibiotic active against C trachomatis within a month. This model can distinguish women with low, medium, and high risks of chlamydial infection (on derivation set: receiver operating characteristic curve area, 0.710; SE, 0.026; on validation set: area, 0.698; SE, 0.035) using simple clinical information obtained in the office.
Adolescent↗
Teaching old dogs new tricks: using cognitive feedback to improve physicians' diagnostic judgments on simulated cases.
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Cognition↗
Are two (inexperienced) heads better than one (experienced) head? Averaging house officers' prognostic judgments for critically ill patients.
Inexperienced physicians may make prognostic judgments and management decisions about acutely ill patients in the absence of supervision. We hypothesized that mathematically combining judgments of junior and senior house officers might yield aggregate judgments as good as those made by experienced critical care attending physicians. We obtained independent quantitative assessments of the likelihood of in-hospital survival for 269 sequential intensive care unit admissions from the patient's intern or resident and the critical care fellow and attending physician on duty within 24 hours of admission, and compared these judgements with mortality data. By logistic regression, the residents' and fellows' judgments added independent prognostic information to each other (likelihood ratio chi 2, 7.6; df = 1). The junior house officers' and fellows' assessments were significantly less reliable than the attending physicians' by calibration curves, and by Brier scores, 0.126 and 0.127 vs 0.119. All physicians had good discriminating ability (receiver operating characteristic areas [SE] were 0.83 [0.03], 0.85 [0.03], 0.86 [0.03], respectively). A simple average of the residents' and fellows' judgments was slightly but significantly more reliable by calibration curve and by Brier score, 0.117, and as discriminating (ROC area = 0.85, SE = 0.03) as the attending physicians' judgments. Nonmedical studies have shown that averaging independent judgments may compensate for people's tendency to make extreme estimates, and may take advantage of their complementary abilities. This first medical application of this technique suggests that this form of voting by secret ballot may prove useful for health care teams making other judgments and decisions.
Clinical Competence↗
The answer to "What are my chances, doctor?" depends on whom is asked: prognostic disagreement and inaccuracy for critically ill patients.
Physicians often must make prognostic judgments for critically ill patients, but we know little about how well they can perform this task. We prospectively measured disagreements among different physicians' quantitative prognostic judgments for 269 sequential admissions to an ICU, and evaluated the accuracy and discriminating ability of judgments made by different types of physicians. Many (44.7%) patients provoked one or more disagreements of at least 20 percentage points among the three possible pairings of physicians. Many patients whom one physician thought were certain to survive did not inspire such certainty in another of their doctors. The critical care attendings thought the changes of survival were less than or equal to 80% for 23, and between 81% and 95% for another 46 of 85 patients whom the patients' own attendings thought were certain to survive. There were some differences in the accuracy of the different physicians' estimates. All doctors showed excellent overall discriminating ability, but discriminated less well for postoperative patients. Lack of consensus about how to judge prognosis for critically ill patients may make it difficult to decide whom to admit to ICUs. These results underscore the need for valid predictive models to aid in decision-making for critically ill patients.
Adult↗
Severity of anaemia and operative mortality and morbidity.
In a case-control study of 125 surgical patients who declined blood transfusions for religious reasons operative mortality was inversely related to the preoperative haemoglobin level, rising from 7.1% for patients with levels above 10 g/dl to 61.5% for those with levels below 6 g/dl. Mortality rates were also related to blood loss during surgery, rising from 8% for patients who lost less than 500 ml to 42.9% for those who lost more than 2000 ml. Both preoperative haemoglobin level and operative blood loss should be considered in assessing the need for preoperative transfusion. In our study no patient with a haemoglobin level above 8 g/dl and operative blood loss below 500 ml died.
Analysis of Variance↗
The comparative cost-effectiveness of statistical decision rules and experienced physicians in pharyngitis management.
We examined whether probability-based decisions for streptococcal pharyngitis, using probabilities derived from predictive models along with Tompkins' decision rules, could be more cost-effective than the actual decisions of ten physicians. We retrospectively calculated the probability of a positive throat culture ("disease") for each of 310 patients using four different models based on discriminant analysis (1), a branching algorithm (2), and logistic regression (3 and 4). "Projected decisions" were based on these probabilities and Tompkins' rules. We calculated direct medical and indirect costs per correct action taken (diseased patient-treated or nondiseased patient-not-treated). Two models' projected decisions were more cost-effective than the physicians'. Model 1 primarily would have reduced treatment costs (leaving no diseased patient untreated); model 4 primarily would have reduced throat culture costs (with 15% projected undertreatment). While using statistical decision rules may be cost-effective in this setting, their adoption should be consistent with physician and patient priorities.
Algorithms↗
The importance of disease prevalence in transporting clinical prediction rules. The case of streptococcal pharyngitis.
Because clinical prediction rules often are applied in new settings to calculate the probability of a disease, we evaluated the accuracy of three rules for predicting streptococcal pharyngitis in 310 patients. Use of the rules led to overestimations of disease probability in 47%, 82%, and 93% of the patients. When we used receiver-operating characteristic curve analysis, no rule lost power to discriminate streptococcal from nonstreptococcal causes of pharyngitis. The overestimations in disease probability likely were caused by differences in disease prevalence between our setting (5%) and the settings in which they were developed (15% to 17%). All rules led to accurate predictions when they were adjusted for the disease prevalence found in our setting using a likelihood ratio formulation of Bayes' theorem. The value of prediction rules, like that of other diagnostic tests, is affected by differences in disease prevalence in different settings. Failure to recognize and adjust for these differences may cause poor decision making or the premature dismissal of valid rules.
Humans↗
A strategy to improve the utilization of pneumococcal vaccine.
OBJECTIVE: To evaluate the effectiveness of a computerized reminder for pneumococcal vaccination at hospital discharge and to determine patient and physician characteristics associated with increased use of the vaccine. DESIGN: Pre- and postintervention study. SETTING: All medical services in a university teaching hospital. PARTICIPANTS: All patients with at least one indication for pneumococcal vaccination discharged from the hospital during one of two three-month time periods; resident and faculty physicians caring for the same patients. INTERVENTIONS: Incorporation of a predischarge reminder for pneumococcal vaccination in the hospital information system. MEASUREMENTS AND MAIN RESULTS: Of 539 eligible patients discharged during the three months after the intervention, 244 (45%) received the vaccine compared with 16 of 474 (3.4%) before the intervention (p less than 0.0001). Following the intervention, patients discharged with a diagnosis of alcoholism were more likely to receive the vaccine than were those without that diagnosis (58.1% vs. 42.7%, p less than 0.05), while patients with a diagnosis of cancer were less likely to get the vaccine (42 of 130, or 32.3%) than were those without cancer (202 of 409, 49.3%) (p less than 0.01). Patients whose attending physicians specialized in hematology-oncology or cardiology were also less likely to receive the vaccine than were all other patients. With the intervention in place, physicians were more likely to vaccinate patients with more than one indication for pneumococcal vaccine. CONCLUSIONS: 1) A predischarge reminder is an inexpensive, effective method to improve physicians' utilization of pneumococcal vaccine in high-risk patients; 2) additional improvements in pneumococcal vaccine utilization will require selective components directed toward specific diagnoses or attending physician subspecialities.
Aged↗
Physician detection of drinking problems in patients attending a general medicine practice.
OBJECTIVE: To assess the patient and physician characteristics that influence physicians' detection of problem drinking in their medical patients. SETTING: The outpatient medical clinic at an urban university teaching hospital staffed by interns and residents. DESIGN: Cross-sectional study of a randomly chosen subsample of consecutive patients. MEASUREMENT: Univariate and multivariate analysis with calculated adjusted odds ratios of factors associated with physician detection of drinking problems. A problem was diagnosed according to the patient's results on the alcohol module of the Diagnostic Interview Schedule (DIS). RESULTS: Physicians detected 22% of 189 presumably inactive problems and 49% of 92 current problems, i.e., those that have occurred within the preceding year. Multivariate correlates of detection of active problems included male patient gender, presence of gastrointestinal complications of excessive drinking, number of concurrent medical disorders, and previous medical record reference to alcohol (p less than 0.05). Physician gender and year of training were not associated with detection. CONCLUSION: Our physicians appear to rely on specific patient characteristics as well as the patient's medical record to detect drinking problems in their ambulatory patients. Their reliance upon these factors may hinder their detection of drinking problems in women patients and less seriously impaired individuals.
Alcoholism↗
Evaluating physicians' probabilistic judgments.
Physicians increasingly are challenged to make probabilistic judgments quantitatively. Their ability to make such judgments may be directly linked to the quality of care they provide. Many methods are available to evaluate these judgments. Graphic means of assessment include the calibration curve, covariance graph, and receiver operating characteristic (ROC) curve. Statistical tools can measure the significance of departures from ideal calibration, and measure the area under ROC curve. Modeling the calibration curve using linear or logistic regression provides another method to assess probabilistic judgments, although these may be limited by failure of the data to meet the model's assumptions. Scoring rules provide indices of overall judgmental performance, although their reliability is difficult to gauge for small sample sizes. Decompositions of scoring rules separate judgmental performance into functional components. The authors provide preliminary guidelines for choosing methods for specific research in this area.
Decision Theory↗
What difference do two days make? The inertia of physicians' sequential prognostic judgments for critically ill patients.
Medical authorities have asserted the importance of observing a patient's clinical course over time. Distinguished committees have suggested that changes over time in physicians' prognostic estimates should influence decisions to transfer patients out of intensive care units (ICUs). This study evaluated how the opportunity to observe patients over time affected physicians' prognostic estimates for a cohort of 269 critically ill patients sequentially admitted to a medical-surgical ICU in a teaching hospital. As soon as possible after admission and again 48 hours later, the authors obtained a quantitative estimate of the probability of survival through hospital discharge from each patient's house officer and primary attending physician, and the critical care attending physician on duty. They independently determined each patient's survival. From this population they analyzed 181 pairs of judgments made by the same house officers, 211 pairs by the same primary attendings, and 172 pairs by the same critical care attendings. The physicians' 48-hour estimates were little changed from their previous estimates for the same patients. The correlation coefficient for the house officers' paired estimates was 0.84 (p less than 0.0001); for the critical care attendings' estimates 0.84 (p less than 0.0001), and for the primary attendings' estimates, 0.90 (p less than 0.0001). Forty-eight hours did not substantially reduce the disagreements present between estimates made by different physicians for the same patient. No group of physicians substantially improved the reliability or the discriminating power of its later estimates. The physicians in the study could not take advantage of sequential clinical information over time. These results point out the need to teach physicians how to better integrate and process sequential clinical data.
Critical Care↗
Availability, wishful thinking, and physicians' diagnostic judgments for patients with suspected bacteremia.
A prospective cohort study was done to assess the effects of value bias and the inappropriate use of the availability heuristic on physicians' judgments of the probability of bacteremia. Subjects of the study were 227 medical inpatients in a university hospital who had blood cultures done. Estimates of the probabilities that individual patients would have positive blood cultures were collected from the house officers who ordered the cultures. Clinical data and culture results were also obtained. Based on the data the authors calculated "value variables," reflecting doctors' assessments of the risks that individual patients would die in the hospital if they were to have bacteremia. "Recalled experience variables" reflected the doctors' recollections of recent experiences with patients with bacteremia. The physicians significantly overestimated the likelihood of bacteremia for most of their patients. Their ROC curve for this diagnosis showed moderate discriminating ability (area = 0.687, SE = 0.073). Two recalled experience variables were significantly associated with the physicians' probability estimates. The value variables were significantly inversely associated with them. These relationships were independent of several clinical variables and measures of disease severity. The physicians' intuitive diagnostic judgments were thus influenced by the availability heuristic and by wishful thinking, a form of the value bias. The availability heuristic may mislead physicians by causing them to believe that random variations in the prevalence of a nonepidemic disease represent real trends. Wishful thinking may lead physicians to underestimate the likelihood of a disease for patients most at risk for its consequences. Teaching physicians to develop better judgmental strategies may improve the quality of their judgments and hence their patient care.
Anti-Bacterial Agents↗