Time-of-day changes in physician clinical decision making: A retrospective study

Background Time of day has been associated with variations in certain clinical practices such as cancer screening rates. In this study, we assessed how more general process measures of physician activity, particularly rates of diagnostic test ordering and diagnostic assessments, might be affected by time of day. Methods We conducted a retrospective chart review of 3,342 appointments by 20 attending physicians at five outpatient clinics, matching appointments by physician and comparing the average diagnostic tests ordered and average diagnoses assessed per appointment in the first hour of the day versus the last hour of the day. Statistical analyses used sign tests, two-sample t-tests, Wilcoxon tests, Kruskal Wallis tests, and multivariate linear regression. Results Examining physicians individually, four and six physicians, respectively, had statistically significant first- versus last-hour differences in the number of diagnostic tests ordered and number of diagnoses assessed per patient visit (p ≤ 0.04). As a group, 16 of 20 physicians ordered more tests on average in the first versus last hour (p = 0.012 for equal chance to order more in each time period). Substantial intra-clinic heterogeneity was found in both outcomes for four of five clinics (p < 0.01). Conclusions There is some statistical evidence on an individual and group level to support the presence of time-of-day effects on the number of diagnostic tests ordered per patient visit. These findings suggest that time of day may be a factor influencing fundamental physician behavior and processes. Notably, many physicians exhibited significant variation in the primary outcomes compared to same-specialty peers. Additional work is necessary to clarify temporal and inter-physician variation in the outcomes of interest.

Patient Satisfaction with Private Recovery Services and Importance of Physician Behavior during COVID Time

Introduction: Patient satisfaction represents an essential indicator of the quality of care in the medical recuperation sector. This study aimed to identify the degree of satisfaction in patients who benefit from medical recuperation services in one private clinic from Romania and the factors that played a part in this respect. Method: An online questionnaire was completed by 105 patients of a private clinic in the period immediately following the opening of the clinic after the quarantine period due to COVID-19. The following concepts were measured: general satisfaction with clinical recuperation services (SG), physician’s behavior (PB), the impact of interventions on the state of health (IHI), modern equipment (ME), and the intention to return to the clinic (IRC). Based on a linear regression model, the impact of PB, IHI, ME, and IRC variables on general satisfaction (SG) was established. Results: The study results confirm the data from studies carried out in different sociocultural contexts in ordinary time, where physician behavior is the most crucial factor in patients’ satisfaction. Therefore, we can say that the physiotherapist’s behavior has an essential role in determining the patients’ satisfaction both in ordinary time and in COVID-19 time. The data in this study reflect the fact that satisfaction with the services offered by a medical recuperation clinic is a predictor for using the services in the future. Still, our study reflects a moderate relationship in intensity.

#61: Antibiotic Use for Community-Acquired Pneumonia Among Hospitalized Children in Japan

Background Judicious use of antimicrobials is the cornerstone of action against antimicrobial resistance. Respiratory tract infections account for over 80% of pediatric antibiotic use in Japan. Antibiotics are generally used empirically for most hospitalized patients with pneumonia although it is becoming clearer that viral etiologies account for approximately 70% of these cases. Defining the characteristics of patients who are managed with a short course of antibiotics and subsequently do well, may lead to setting clinical criteria for early termination of antibiotics. Methods We performed a retrospective descriptive analysis. Medical charts of patients aged 3 months to 18 years, who were admitted with a diagnosis of pneumonia, bronchitis, bronchiolitis, or asthma to the Department of Interdisciplinary medicine at the National Center for Child Health and Development from March 2018 through February 2019 were reviewed. Those who had respiratory symptoms and were started on antibiotics within 48 hours of hospitalization were included. Those who had a focus of infection elsewhere or were immunocompromised were excluded. Results Of the 556 candidates, 80 patients met the criteria. The median age was 1.5 years which included 42.5% (34/80) with comorbidities. Underlying conditions included 9 with trisomy 21, and 8 with perinatal issues. Rapid antigen testing was performed and 7 patients with RSV, 5 patients with influenza, 1 patient with human metapneumovirus were identified. The average duration of antibiotic therapy was 7.2 days (range 2–14 days). There were no statistical differences in the characteristics of patients who received antibiotics for more or less than 5 days. The positivity of the rapid antigen test tended to be higher in those who received antibiotics for a shorter period (25% vs. 15%). There were no differences in the rate of readmission or complications between the two groups. Conclusion We were unable to identify a clear characteristic of patients who received short courses of antibiotics for pneumonia. The trend observed for those who had a point of care testing may suggest that the use of a multiplex PCR testing covering a greater number of pathogens would influence physician behavior in antibiotic use.

Learning Decision Thresholds for Risk-Stratification Models from Aggregate Clinician Behavior

ABSTRACTUsing a risk-stratification model to guide clinical practice often requires the choice of a cutoff - called the decision threshold - on the model’s output to trigger a subsequent action such as an electronic alert. Choosing this cutoff is not always straightforward. We propose a flexible approach that leverages the collective information in treatment decisions made in real life to learn reference decision thresholds from physician practice. Using the example of prescribing a statin for primary prevention of cardiovascular disease based on 10-year risk calculated by the 2013 Pooled Cohort Equations, we demonstrate the feasibility of using real world data to learn the implicit decision threshold that reflects existing physician behavior. Learning a decision threshold in this manner allows for evaluation of a proposed operating point against the threshold reflective of the community standard of care. Furthermore, this approach can be used to monitor and audit model-guided clinical decision-making following model deployment.

Physician Assessment and Feedback During Quality Circle to Reduce Low-Value Services in Outpatients: a Pre-Post Quality Improvement Study

Background The impact of the Choosing Wisely (CW) campaign is debated as recommendations alone may not modify physician behavior. Objective The aim of this study was to assess whether behavioral interventions with physician assessment and feedback during quality circles (QCs) could reduce low-value services. Design and Participants Pre-post quality improvement intervention with a parallel comparison group involving outpatients followed in a Swiss-managed care network, including 700 general physicians (GPs) and 150,000 adult patients. Interventions Interventions included performance feedback about low-value activities and comparison with peers during QCs. We assessed individual physician behavior and healthcare use from laboratory and insurance claims files between August 1, 2016, and October 31, 2018. Main Measures Main outcomes were the change in prescription of three low-value services 6 months before and 6 months after each intervention: measurement of prostate-specific antigen (PSA) and prescription rates of proton pump inhibitors (PPIs) and statins. Key Results Among primary care practices, a QC intervention with physician feedback and peer comparison resulted in lower rates of PPI prescription (pre-post mean prescriptions per GP 25.5 ± 23.7 vs 22.9 ± 21.4, p value<0.01; coefficient of variation (Cov) 93.0% vs 91.0%, p=0.49), PSA measurement (6.5 ± 8.7 vs 5.3 ± 6.9 tests per GP, p<0.01; Cov 133.5% vs 130.7%, p=0.84), as well as statins (6.1 ± 6.8 vs 5.6 ± 5.4 prescriptions per GP, p<0.01; Cov 111.5% vs 96.4%, p=0.21). Changes in prescription of low-value services among GPs who did not attend QCs were not statistically significant over this time period. Conclusion Our results demonstrate a modest but statistically significant effect of QCs with educative feedback in reducing low-value services in outpatients with low impact on coefficient of variation. Limiting overuse in medicine is very challenging and dedicated discussion and real-time review of actionable data may help.

Physician Perceptions of Catching COVID-19

BackgroundRisk perception, influenced and biased by multiple factors, can affect behavior.ObjectiveTo assess the variability of physician perceptions of catching COVID-19.DesignCross sectional, random stratified sample of physicians registered with Sermo, a global networking platform open to verified and licensed physicians.Main outcome measuresThe survey asked: “What is your likelihood of catching COVID-19 in the next three months?” The physicians were asked to give their best estimate as an exact percentage.ResultsThe survey was completed by 1004 physicians (40 countries, 67 specialties, 49% frontline [e.g. ER, infectious disease, internal medicine]) with a mean (SD) age of 49.14 (12) years. Mean (SD) self-risk estimate was 32.3% ± 26% with a range from 0% to 100% (Figure 1a). Risk estimates were higher in younger (<50 years) doctors and in non-US doctors versus their older and US counterparts (p<0.05 for all) (Figure 1b). Risk estimates were higher among front line versus non-frontline doctors (p<0.05). Risk estimates were higher for women than men (p<0.05) among respondents (60%) reporting gender.ConclusionsTo our knowledge, this is the first global study to document physician risk perceptions for catching COVID-19 and how it is impacted by age, gender, practice specialty and geography. Accurate calibration of risk perception is vital since both over- and underestimation of risk could impact physician behavior and have implications for public health.

Antibiotic Overuse After Hospital Discharge: A Multi-hospital Cohort Study

Background Antibiotics are commonly prescribed to patients as they leave the hospital. We aimed to create a comprehensive metric to characterize antibiotic overuse after discharge among hospitalized patients treated for pneumonia or urinary tract infection (UTI), and to determine whether overuse varied across hospitals and conditions. Methods In a retrospective cohort study of hospitalized patients treated for pneumonia or UTI in 46 hospitals between 1 July 2017–30 July 2019, we quantified the proportion of patients discharged with antibiotic overuse, defined as unnecessary antibiotic use, excess antibiotic duration, or suboptimal fluoroquinolone use. Using linear regression, we assessed hospital-level associations between antibiotic overuse after discharge in patients treated for pneumonia versus a UTI. Results Of 21 825 patients treated for infection (12 445 with pneumonia; 9380 with a UTI), nearly half (49.1%) had antibiotic overuse after discharge (56.9% with pneumonia; 38.7% with a UTI). For pneumonia, 63.1% of overuse days after discharge were due to excess duration; for UTIs, 43.9% were due to treatment of asymptomatic bacteriuria. The percentage of patients discharged with antibiotic overuse varied 5-fold among hospitals (from 15.9% [95% confidence interval, 8.7%–24.6%] to 80.6% [95% confidence interval, 69.4%–88.1%]) and was strongly correlated between conditions (regression coefficient = 0.85; P &lt; .001). Conclusions Antibiotic overuse after discharge was common and varied widely between hospitals. Antibiotic overuse after discharge was associated between conditions, suggesting that the prescribing culture, physician behavior, or organizational processes contribute to overprescribing at discharge. Multifaceted efforts focusing on all 3 types of overuse and multiple conditions should be considered to improve antibiotic prescribing at discharge.

Study design and ethical considerations related to using direct observation to evaluate physician behavior: reflections after a recent study

In a recent study using direct observation of physicians, we demonstrated that physician-generated clinical documentation is vulnerable to error. In fact, we found that physicians consistently overrepresented their actions in certain areas of the medical record, such as the physical examination. Because of our experiences carrying out this study, we believe that certain investigations, particularly those evaluating physician behavior, should not rely on documentation alone. Investigators seeking to evaluate physician behavior should instead consider using observation to obtain objective information about occurrences in the patient-physician encounter. In this article, we describe our experiences using observation, and we offer investigators our perspectives related to study design and ethical questions to consider when performing similar work.

Physician Behavior under Prospective Payment Schemes—Evidence from Artefactual Field and Lab Experiments

Recent experimental studies analyze the behavior of physicians towards patients and find that physicians care for their own profit as well as patient benefit. In this paper, we extend the experimental analysis of the physician decision problem by adding a third party which represents the health insurance that finances medical service provision under a prospective payment scheme. Our results show that physicians take into account the payoffs of the third party, which can lead to underprovision of medical care. We conduct a laboratory experiment in neutral as well as in medical framing using students and medical doctors as subjects. Subjects in the medically framed experiments behave weakly and are more patient orientated in contrast to neutral framing. A sample of medical doctors exhibits comparable behavior to students with medical framing.