scholarly journals Diagnosis and treatment of community-acquired pneumonia in patients with acute cough: a quantitative study of decision thresholds in primary care

2018 ◽  
Vol 68 (676) ◽  
pp. e765-e774 ◽  
Author(s):  
Mark H Ebell ◽  
Isabella Locatelli ◽  
Yolanda Mueller ◽  
Nicolas Senn ◽  
Kathryn Morgan
Keyword(s):  
Primary Care ◽  
Primary Care Physicians ◽  
Signs And Symptoms ◽  
Clinical Decision ◽  
Community Acquired Pneumonia ◽  
Multivariate Model ◽  
Clinical Decisions ◽  
Acute Cough ◽  
Treatment Thresholds ◽  
Rule Out

BackgroundTest and treatment thresholds have not yet been described for decision-making regarding the likelihood of pneumonia in patients with acute cough.AimTo determine decision thresholds in the management of patients with acute cough.Design and settingSet among primary care physicians attending meetings in the US and Switzerland, using data from a prospective cohort of primary care patients.MethodClinical vignettes were used to study the clinical decisions of physicians regarding eight patients with cough that varied by six signs and symptoms. The probability of community-acquired pneumonia (CAP) was determined for each vignette based on a multivariate model. A previously published approach based on logistic regression was used to determine test and treatment thresholds.ResultsIn total, 256 physicians made 764 clinical decisions. Initial physician estimates systematically overestimated the likelihood of CAP; 75% estimating a higher probability than that predicted by the multivariate model. Given the probability of CAP from a multivariate model, 16.7% (125 of 749) changed their decision from ‘treat’ to ‘test’ or ‘test’ to ‘rule out’, whereas only 3.5% (26/749) changed their decision from ‘rule out’ to ‘test’ or ‘test’ to ‘treat’. Test and treatment thresholds were 9.5% (95% confidence interval (CI) = 8.7 to 10.5) and 43.1% (95% CI = 40.1 to 46.4) and were updated to 12.7% (95% CI = 11.7 to 13.8) and 51.3% (95% CI = 48.3 to 54.9) once the true probability of CAP was given. Test thresholds were consistent between subgroups. Treatment thresholds were higher if radiography was available, for Swiss physicians, and for non-primary care physicians.ConclusionTest and treatment thresholds for CAP in patients with acute cough were 9.5% and 43.1%, respectively. Physicians tended to overestimate the likelihood of CAP, and providing information from a clinical decision rule (CDR) changed about 1 in 6 clinical decisions.

scholarly journals Use of Heuristics during the clinical decision process in from family physicians in real conditions.

2021 ◽  
Author(s):  
Carmen Fernández Aguilar ◽  
José-Jesús Martín-Martín ◽  
Sergio Minué-Lorenzo ◽  
Alberto Fernández Ajuria
Keyword(s):  
Primary Care ◽  
Decision Process ◽  
Primary Care Physicians ◽  
Clinical Decision ◽  
Diagnostic Error ◽  
Operational Definition ◽  
Statistical Correlation ◽  
Diagnostic Process ◽  
Representativeness Heuristic ◽  
Definition Of

Rationale, aims and objectives: The available evidence on the existence and consequences of the use of heuristics in the clinical decision process is very scarce. The purpose of this study is to measure the use of the Representativeness, Availability and Overconfidence heuristics in real conditions with Primary Care physicians in cases of dyspnea and to study the possible correlation with diagnostic error. Methods: A prospective cohort study was carried out in 4 Primary Care centers in which 371 new cases or dyspnea were registered. The use of the three heuristics in the diagnostic process is measured through an operational definition of the same. Subsequently, the statistical correlation with the identified clinical errors is analyzed. Results: In 9.97% of the registered cases a diagnostic error was identified. In 49.59% of the cases, the physicians used the representativeness heuristic in the diagnostic decision process. The availability heuristic was used by 82.38% of the doctors and finally, in more than 50% of the cases the doctors showed excess confidence. None of the heuristics showed a statistically significant correlation with diagnostic error. Conclusion: The three heuristics have been used as mental shortcuts by Primary Care physicians in the clinical decision process in cases of dyspnea, but their influence on the diagnostic error is not significant. New studies based on the proposed methodology will allow confirming both its importance and its association with diagnostic error.

scholarly journals Clinical decisions and stigmatizing attitudes towards mental health problems in primary care physicians from Latin American countries

PLoS ONE ◽  
2018 ◽  
Vol 13 (11) ◽  
pp. e0206440 ◽  
Author(s):  
Angel O. Rojas Vistorte ◽  
Wagner Ribeiro ◽  
Carolina Ziebold ◽  
Elson Asevedo ◽  
Sara Evans-Lacko ◽  
...  
Keyword(s):  
Mental Health ◽  
Primary Care ◽  
Latin American ◽  
Primary Care Physicians ◽  
Mental Health Problems ◽  
Health Problems ◽  
Clinical Decisions ◽  
Stigmatizing Attitudes ◽  
Latin American Countries

scholarly journals Agent-based Decision Support for Pain Management in Primary Care Settings

2019 ◽  
Author(s):  
Xu Guo ◽  
Han Yu ◽  
Chunyan Miao ◽  
Yiqiang Chen
Keyword(s):  
Primary Care ◽  
Decision Support ◽  
Pain Management ◽  
Primary Care Physicians ◽  
Quality Care ◽  
Management Training ◽  
Clinical Decision ◽  
General Purpose ◽  
Agent Based ◽  
Provide Quality Care

The lack of systematic pain management training and support among primary care physicians (PCPs) limits their ability to provide quality care for patients with pain. Here, we demonstrate an Agent-based Clinical Decision Support System to empower PCPs to leverage knowledge from pain specialists. The system learns a general-purpose representation space on patients, automatically diagnoses pain, recommends therapy and medicine, and suggests a referral program to PCPs in their decision-making tasks.

scholarly journals Signs and Symptoms That Rule out Community-Acquired Pneumonia in Outpatient Adults: A Systematic Review and Meta-Analysis

2019 ◽  
Vol 32 (2) ◽  
pp. 234-247 ◽  
Author(s):  
Christian S. Marchello ◽  
Mark H. Ebell ◽  
Ariella P. Dale ◽  
Eric T. Harvill ◽  
Ye Shen ◽  
...  
Keyword(s):  
Systematic Review ◽  
Meta Analysis ◽  
Signs And Symptoms ◽  
Community Acquired Pneumonia ◽  
Rule Out

Telephone Triage by Primary Care Physicians

PEDIATRICS ◽  
1992 ◽  
Vol 89 (4) ◽  
pp. 701-706 ◽  
Author(s):  
Susan Zelitch Yanovski ◽  
Richard L. Brown ◽  
Donald J. Balaban ◽  
Jack A. Yanovski ◽  
James D. Malley
Keyword(s):  
Primary Care ◽  
Primary Care Physicians ◽  
Pediatric Patients ◽  
Telephone Interview ◽  
First Year ◽  
Telephone Triage ◽  
Private Practitioners ◽  
Sick Children ◽  
Better Than ◽  
Rule Out

To determine if experienced primary care physicians are more likely to reach correct decisions on the telephone than their less experienced colleagues, we asked 31 first-year and 29 third-year residents, 21 faculty, and 36 private practitioners in pediatrics and family practice to evaluate three pediatric patients via a telephone interview with a simulated mother and to decide whether each patient needed to be seen that evening. Compared with first-year residents, the third-year residents, faculty and private practitioners decided less frequently to see children who were not severely ill (P < .05) or injured (P < .01); however, less than half obtained histories considered adequate to rule out potential serious illnesses. Faculty did better than either residents or private practitioners in managing a severely dehydrated child; 100% of the faculty, but less than 60% of the residents or private practitioners, chose to see the patient promptly (P < .001). More than one third of all residents and private practitioners reached inappropriate management decisions despite obtaining information that should have altered their decisions. In these simulations, experience in private practice was not associated with improved telephone management of very sick children. Faculty physicians appeared to be better able to identify severely ill children without inappropriately evaluating those who were less ill. In all three simulations, attainment of the correct decision appeared to be determined not by the number or type of questions asked, but rather by the physician's interpretation of the information collected.

scholarly journals Coughing children in family practice and primary care: a systematic review of prevalence, aetiology and prognosis

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Milena Bergmann ◽  
Jörg Haasenritter ◽  
Dominik Beidatsch ◽  
Sonja Schwarm ◽  
Kaja Hörner ◽  
...  
Keyword(s):  
Systematic Review ◽  
Primary Care ◽  
Respiratory Tract ◽  
Chronic Cough ◽  
Primary Care Physicians ◽  
Original Research ◽  
Current Guideline ◽  
Upper Respiratory Tract ◽  
Acute Cough ◽  
Tract Infections

Abstract Background For evidence-based decision making, primary care physicians need to have specific and reliable information on the pre-test probabilities of underlying diseases and a symptom’s course. We performed a systematic review of symptom-evaluating studies in primary care, following three research questions: (1) What is the prevalence of the symptom cough in children consulting primary care physicians? (2) What are the underlying aetiologies of cough and the respective frequencies? (3) What is the prognosis of children with cough? Methods Following a pre-defined algorithm and independent double reviewer ratings we searched MEDLINE and EMBASE. All quantitative original research articles in English, French or German were included if they focused on unselected study populations of children consulting a primary care physician for cough. We used the random effects model for meta-analysis in subgroups, if justifiable in terms of heterogeneity. Results We identified 14 eligible studies on prevalence, five on aetiology and one on prognosis. Prevalence estimates varied between 4.7 and 23.3% of all reasons for an encounter, or up to estimates of 60% when related to patients or consultations. Cough in children is more frequent than in adults, with lowest prevalences in adolescents and in summer. Acute cough is mostly caused by upper respiratory tract infections (62.4%) and bronchitis (33.3%); subacute or chronic cough by recurrent respiratory tract infection (27.7%), asthma (up to 50.4% in cough persisting more than 3 weeks), and pertussis (37.2%). Potentially serious diseases like croup, pneumonia or tuberculosis are scarce. In children with subacute and chronic cough the total duration of cough ranged from 24 to 192 days. About 62.3% of children suffering from prolonged cough are still coughing two months after the beginning of symptoms. Conclusion Cough is one of the most frequent reasons for an encounter in primary care. Our findings fit in with current guideline recommendations supporting a thoughtful wait-and-see approach in acute cough and a special awareness in chronic cough of the possibility of asthma and pertussis. Further evidence of aetiological pre-test probabilities is needed to assess the diagnostic gain based on patient history and clinical signs for differential diagnoses of cough in children.

scholarly journals Measuring and Improving Evidence-Based Patient Care Using a Web-Based Gamified Approach in Primary Care (QualityIQ): Randomized Controlled Trial (Preprint)

2021 ◽  
Author(s):  
Trever Burgon ◽  
Linda Casebeer ◽  
Holly Aasen ◽  
Czarlota Valdenor ◽  
Diana Tamondong-Lachica ◽  
...  
Keyword(s):  
Primary Care ◽  
Real Time ◽  
Primary Care Physicians ◽  
Primary Care Providers ◽  
The United States ◽  
Physician Satisfaction ◽  
Evidence Based ◽  
Clinical Decisions ◽  
Care Providers ◽  
Evidence Based Care

BACKGROUND Unwarranted variability in clinical practice is a challenging problem in practice today, leading to poor outcomes for patients and low-value care for providers, payers, and patients. OBJECTIVE In this study, we introduced a novel tool, QualityIQ, and determined the extent to which it helps primary care physicians to align care decisions with the latest best practices included in the Merit-Based Incentive Payment System (MIPS). METHODS We developed the fully automated QualityIQ patient simulation platform with real-time evidence-based feedback and gamified peer benchmarking. Each case included workup, diagnosis, and management questions with explicit evidence-based scoring criteria. We recruited practicing primary care physicians across the United States into the study via the web and conducted a cross-sectional study of clinical decisions among a national sample of primary care physicians, randomized to continuing medical education (CME) and non-CME study arms. Physicians “cared” for 8 weekly cases that covered typical primary care scenarios. We measured participation rates, changes in quality scores (including MIPS scores), self-reported practice change, and physician satisfaction with the tool. The primary outcomes for this study were evidence-based care scores within each case, adherence to MIPS measures, and variation in clinical decision-making among the primary care providers caring for the same patient. RESULTS We found strong, scalable engagement with the tool, with 75% of participants (61 non-CME and 59 CME) completing at least 6 of 8 total cases. We saw significant improvement in evidence-based clinical decisions across multiple conditions, such as diabetes (+8.3%, <i>P</i>&lt;.001) and osteoarthritis (+7.6%, <i>P</i>=.003) and with MIPS-related quality measures, such as diabetes eye examinations (+22%, <i>P</i>&lt;.001), depression screening (+11%, <i>P</i>&lt;.001), and asthma medications (+33%, <i>P</i>&lt;.001). Although the CME availability did not increase enrollment in the study, participants who were offered CME credits were more likely to complete at least 6 of the 8 cases. CONCLUSIONS Although CME availability did not prove to be important, the short, clinically detailed case simulations with real-time feedback and gamified peer benchmarking did lead to significant improvements in evidence-based care decisions among all practicing physicians. CLINICALTRIAL ClinicalTrials.gov NCT03800901; https://clinicaltrials.gov/ct2/show/NCT03800901

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