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Study objectives: To assess the accuracy of physicians’ judgments of survival probability for medically managed patients with coronary artery disease (CAD), and of the absolute risk reduction of mortality due to coronary artery bypass grafting (CABG) or percutaneous transluminal coronary angioplasty (PTCA) for such patients; and relationships among these judgments and the physicians’ propensity to perform revascularization. Design: Two surveys (for three-vessel or two-vessel CAD) for patients presenting with stable CAD, currently managed medically, and without other life-limiting problems. Setting: Multiple educational conferences, 1996 –1997. Participants: Conference attendees. Measurements and results: Main outcomes were proportions of patients for whom the physicians would recommend revascularization (CABG for three-vessel CAD, CABG or PTCA for two-vessel CAD), and judgments of the proportions of medically managed patients who would be alive after 5 years, 7 years, and 11 years, and of absolute risk reduction of mortality due to CABG (or PTCA for two-vessel CAD). At least one half of the participants judged the survival rate of medically managed patients with three-vessel or two-vessel CAD to be less than the lowest rates supported by the best available evidence. More than one fourth judged the absolute risk reduction due to CABG to be higher than the highest values based on such evidence. Physicians’ propensity to perform revascularization correlated inversely with their judgments of survival given medical management, and with their judgments of absolute risk reduction due to revascularization. Conclusions: Physicians may overuse revascularization because of excessive pessimism about survival of medically managed patients, and excessive optimism about the survival benefits of revascularization (CHEST 2002; 122:122–133)

Study objectives: To determine how well triage physicians judge the probability of death or severe complications that require treatment only available in an ICU to maintain life for patients with acute congestive heart failure (CHF). Design: Prospective cohort study. Setting: An urban university hospital, a Veteran’s Administration hospital, and a community hospital. Patients or participants: Patients were those visiting the emergency department (ED) with acute CHF, excluding those who already required a treatment only available in an ICU to maintain life, and those with possible or definite myocardial infarction. Physician participants were those caring for the patients in the ED. Measurements and results: We performed chart reviews to ascertain whether each patient died or had severe complications develop by 4 days. We collected judgments of the probability of this outcome from the physicians taking care of the study patients in the ED. The prevalence of death or severe complications was 43 per 1,032 patients (4.2%). The mean SD of physicians’ judgments of the probability of this outcome was 32.1 28.4%. A calibration curve that stratified these judgments by decile demonstrated that physicians consistently overestimated this probability (p < 0.01). Physicians’ judgments were only moderately good at discriminating which patients would have the outcome (receiver operating characteristic curve area, 0.715). Patients admitted to an ICU received the highest average predicted probability (56.4%), followed by those admitted to a telemetry unit (34.1%), to a regular hospital ward (29.8%), and those sent home (17.9%.) Conclusions: Physicians drastically overestimated the probability of a severe complication that would require critical care for patients with acute CHF who were candidates for ICU admission. Their judgments of this probability were associated with their triage decisions, as they should be according to several guidelines for ICU triage. Overestimation of the probability of severe complications may have lead to overutilization of scarce critical care resources. Current critical care triage guidelines should be revised to take this difficulty into account, and better predictive models for patients potentially requiring critical care should be developed. (CHEST 2002; 121:1610–1617)

This study examines the association between type of internal medicine training and satisfaction ratings among 509 patients who visited the clinic of an urban teaching hospital over a 3-month period in 1994. When controlling for patient, health-system, and other resident factors, primary care training was significantly associated with higher satisfaction ratings (cumulative odds ratio 1.53; 95% confidence interval 1.04, 2.25; p = .031) than categorical training. Using satisfaction ratings to rank the residents without adjusting for patient and health-system factors would have correctly classified only 27% of the residents in the lowest quartile. These findings have implications for both the education and potential employment of internists.

The objective of this study was to determine the rate of bacteremia in young women admitted to the hospital with presumed pyelonephritis and compare it with other published rates. The study design was a retrospective, structured chart review and a review of published reports of bacteremic pyelonephritis. An urban county teaching hospital provided the setting for the study. The patients were nonpregnant women (n = 98) 44 years of age or younger who were without bladder dysfunction and who had not been admitted to an intensive care unit. Further criteria for participation included discharge with the diagnosis of acute pyelonephritis. Blood cultures were ordered for 69 women; the results of 64 were noted in the chart. Twenty-three women (35.9% of those cultured; 23.4% of all patients) were diagnosed with bacteremia. In patients for whom blood culture results were obtained, trends developed between those patients with bacteremia and those with complicated pyelonephritis, defined as a known or newly discovered genitourinary abnormality or a risk factor (P = 0.044), those who were black (P = .044), those with higher pulses on admission (P = .050), those with more white blood cells per high-powered field after urinalysis (P = 0.007), and those whose fever lasted longer (P = 0.033). Blood culture results were positive in two patients whose urine cultures were negative. This comparatively high bacteremia rate supports routine ordering of blood cultures for urban women suspected of having pyelonephritis.

OBJECTIVE: To better understand primary treatment recommendations and the variables that might influence treatment decisions of physicians who treat agitated dementia patients. DESIGN: A written cross-sectional survey of three physician groups (geriatric psychiatrists, primary care physicians, and neurologists) who typically treat agitated dementia patients in community settings. We used a written clinical vignette describing a home-bound, agitated dementia patient to ask respondents to provide information regarding their primary treatment recommendation and to estimate the degree to which clinically relevant variables might influence their treatment recommendation. Using principal component analysis, the original set of clinical variables was collapsed into a smaller set of composite factors that better defined the fundamental constructs of the variables that influenced decision making. Analyses compared primary treatment recommendations and factors influencing treatment recommendations by physician groups. PARTICIPANTS: The pool of survey respondents consisted of a random selection of 207 primary care physicians from western North Carolina, 147 geriatric psychiatrists obtained from the roster of the 1991 American Association for Geriatric Psychiatry, and 120 neurologists obtained from the roster of the American Board of Medical Specialties. The response rate was 65% for geriatric psychiatrists, 38% for primary care physicians, and 33% for neurologists. RESULTS: Differences in primary treatment recommendations by physician group were not found. Physicians, regardless of specialty, recommended neuroleptic medications as their primary intervention. When medication classes were collapsed into a single category, medications as a primary intervention exceeded 55% for all physician groups. Twenty-two percent of all respondents recommended psychosocial interventions as primary treatment strategies. The principal component analysis of clinical variables influencing treatment recommendations solved for five components that accounted for 64% of the variance. Comparing the five components by specialty groups failed to find significant differences, except for Factor 5, the “Hassle Factor.” Primary care physicians were more likely to indicate that this component influenced their decision making than were the other physician groups. CONCLUSIONS: The findings indicate that physicians, regardless of specialty, are likely to use medication and to weight clinically relevant information in a similar fashion when managing agitated dementia patients. J Am Geriatr Soc 44:1375–1379, 1996.

Guidelines have been offered on haemoglobin thresholds for blood transfusion in surgical patients. However, good evidence is lacking on the haemoglobin concentrations at which the risk of death or serious morbidity begins to rise and at which transfusion is indicated.A retrospective cohort study was performed in 1958 patients, 18 years and older, who underwent surgery and declined blood transfusion for religious reasons. The primary outcome was 30-day mortality and the secondary outcome was 30-day mortality or in-hospital 30-day morbidity. Cardiovascular disease was defined as a history of angina, myocardial infarction, congestive heart failure, or peripheral vascular disease.The 30-day mortality was 3.2% (95% CI 2.4-4.0). The mortality was 1.3% (0.8-2.0) in patients with preoperative haemoglobin 12 g/dL or greater and 33.3% (18.6-51.0) in patients with preoperative haemoglobin less than 6 g/dL. The increase in risk of death associated with low preoperative haemoglobin was more pronounced in patients with cardiovascular disease than in patients without (interaction p0.03). The effect of blood loss on mortality was larger in patients with low preoperative haemoglobin than in those with a higher preoperative haemoglobin (interaction p0.001). The results were similar in analyses of postoperative haemoglobin and 30-day mortality or in-hospital morbidity.A low preoperative haemoglobin or a substantial operative blood loss increases the risk of death or serious morbidity more in patients with cardiovascular disease than in those without. Decisions about transfusion should take account of cardiovascular status and operative blood loss as well as the haemoglobin concentration.

The objective of this study was to determine how well the Charlson index of comorbidity would predict mortality of critically ill patients; and how the predictive ability of the index would compare with that of the comorbidity component (Chronic Health Points) of the APACHE II system. This prospective cohort study included in its setting an intensive care unit (ICU) and intermediate ICU (IICU) in a teaching hospital. Patients included a previously assembled inception cohort of 201 patients consecutively admitted to either unit, followed until death or discharge from the hospital, excluding patients admitted after coronary artery bypass grafting, for planned dialysis, or transferred to the IICU from another intensive care unit. Main outcome measures were recorded as death in hospital versus survival at discharge. For each patient we had prospectively obtained all data necessary to predict the probability of in-hospital death using the APACHE II system, and to classify comorbidity using the Charlson index. The Charlson index had significant ability to discriminate between patients who would live and who would die (ROC curve area = 0.67, SE = 0.05). The Chronic Health Points component of APACHE II had no significant discriminating ability (ROC area = 0.57, SE = 0.05), although the full APACHE II system was an excellent predictor (area = 0.87, SE = 0.04). Logistic regression analyses suggested that the Charlson index could contribute significant (p = 0.03) prognostic information to that obtained from the components of APACHE II other than Chronic Health, i.e., acute physiological derangement, age, and reason for admission, but the Chronic Health Points component of APACHE II could not so contribute to the rest of APACHE II (p = 0.19). Our conclusion is that use of the detailed information about comorbidity captured by the Charlson index could improve prognostic predictions even for critically ill patients.

Several studies have shown differences in the rates at which women and men receive treatment for several common medical problems, especially heart disease. The reason for these differences and the extent to which men and women receive different treatments for other problems is unclear. The purpose of the current study was to determine whether there are differences in the rates men and women receive antibiotic therapy for pharyngitis (sore throat), whether these differences are related to differences in disease severity or comorbidity across the sexes, and whether these differences could be due to prejudice against women by male clinicians. This was a retrospective analysis of data at two university student health services in Pennsylvania and Nebraska. Male clinicians did not prescribe antibiotics at significantly different rates for male and female patients, but female clinicians prescribed antibiotics more frequently for their male patients.

This commentary discusses how clauses in the contracts that physicians sign with their employers or that their employers sign with third parties may be part of a growing class of subtle restriction...

Objective Blood loss during surgery is an important operative complication in patients undergoing major noncardiac surgery and may increase postoperative morbidity and mortality. Variations in the delivery of operative blood transfusions to treat blood loss depend not only on the patient and surgery characteristics but also on the hospital transfusion practices, and may explain differences in the hospitals' postoperative outcomes. We determine the relationship between hospital-level rates of intraoperative blood transfusion and 30-day mortality among older patients with significant intraoperative blood loss. Methods Among 46,608 operative patients aged 65 years or older whose estimated blood loss was 500 mL or greater in 122 Veterans Affairs (VA) hospitals during years 1997 to 2004, we examined the relationship between hospital-level transfusion rates and adjusted 30-day postoperative mortality rates using linear regression modeling. Results Hospital-level rates of intraoperative blood transfusion for older surgical patients with significant blood loss varied from 10% to 92%. Hospitals in the highest tertile for the rate of intraoperative transfusion had the highest number of patients with 500 mL or more surgical blood loss and lowest risk-adjusted 30-day surgical mortality. For every 10% increase in the rate of intraoperative blood transfusion, there was a 0.7% (95% CI: 0.3%-1.1%) decrease in the hospital's adjusted 30-day postoperative mortality for these high-risk patients. Conclusions Large variation exists in hospitals' intraoperative blood transfusion practices for older patients with significant surgical blood loss. Hospitals with higher transfusion rates for patients with significant surgical blood loss have lower adjusted 30-day mortality for these patients. Hospital intraoperative blood transfusion practices may be a promising surgical quality indicator.

In this paper, probabilities of survival assessed by physicians for patients admitted to an intensive care unit are studied. The probabilities from each of four types of physicians are evaluated on an overall basis and in terms of specific attributes, and the groups are compared. The physicians with the most experience and expertise perform better overall. All four groups appear to be reasonably well calibrated, and the key factor in relative overall performance is the level of discrimination provided by the probabilities. Averages of two, three, and four probabilities for each individual patient are also analyzed. As the number of the probabilities in the average increases, performance improves on average on all dimensions, although the best overall performance is exhibited by a combination of probabilities from the two physician types performing best individually. Some comparisons are made with previous work, and implications for probability assessment and combination in medicine and more generally in other areas of application are discussed. Important characteristics of the study are the fact that it was conducted on-line in a real setting, the involvement of individuals with different levels of expertise, the use of a true predictive situation with a clearly-defined event, the consideration of multiple dimensions of the quality of judgments, and the collection of multiple probabilities for each case to permit the investigation of a variety of possible combinations of probabilities.

Anemia and operative blood loss are common in the elderly, but evidence is lacking on whether intraoperative blood transfusions can reduce the risk of postoperative death.We analyzed retrospective data from 239,286 patients 65 years of older who underwent major noncardiac surgery in 1997 to 2004 at veteran hospitals nationwide. Propensity-score matching was used to adjust for differences between patients who received intraoperative blood transfusions (9.4%) and those who did not, and data were used to determine the association between intraoperative blood transfusion and 30-day postoperative mortality.After propensity-score matching, intraoperative blood transfusion was associated with mortality risk reductions in patients with preoperative hematocrit levels of24% (odds ratio: 0.60, 95% CI: 0.41-0.87), and in patients with hematocrit of 30% or greater when there is substantial (500-999 mL) blood loss (odds ratio: 0.35, 95% CI: 0.22-0.56 for hematocrit levels between 30%-35.9% and 0.78, 95% CI: 0.62-0.97 for hematocrit levels of 36% or greater). When operative blood loss was500 mL, transfusion was not associated with mortality reductions for patients with hematocrit levels of 24% or greater, and conferred increased mortality risks in patients with preoperative hematocrit levels between 30% to 35.9% (odds ratio 1.29, 95% CI: 1.04-1.60).Intraoperative blood transfusion is associated with a lower 30-day postoperative mortality among elderly patients undergoing major noncardiac surgery if there is substantial operative blood loss or low preoperative hematocrit levels (24%). Transfusion is associated with increased mortality risks for those with preoperative hematocrit levels between 30% and 35.9% and500 mL of blood loss.

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.A prospective study of an inception cohort of critically ill patients followed until death or discharge from the hospital.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.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).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.

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 varia bles," 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' prob ability 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 heu ristic 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 non- epidemic disease represent real trends. Wishful thinking may lead physicians to underes timate 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. Key words: diagnosis; probability; septicemia; availability heu ristic ; value bias. (Med Decis Making 1991;11:159-168)

Background There are many examples of physicians using treatments inappropriately, despite clear evidence about the circumstances under which the benefits of such treatments outweigh their harms. When such over- or under- use of treatments occurs for common diseases, the burden to the healthcare system and risks to patients can be substantial. We propose that a major contributor to inappropriate treatment may be how clinicians judge the likelihood of important treatment outcomes, and how these judgments influence their treatment decisions. The current study will examine the role of judged outcome probabilities and other cognitive factors in the context of two clinical treatment decisions: 1) prescription of antibiotics for sore throat, where we hypothesize overestimation of benefit and underestimation of harm leads to over-prescription of antibiotics; and 2) initiation of anticoagulation for patients with atrial fibrillation (AF), where we hypothesize that underestimation of benefit and overestimation of harm leads to under-prescription of warfarin. Methods For each of the two conditions, we will administer surveys of two types (Type 1 and Type 2) to different samples of Canadian physicians. The primary goal of the Type 1 survey is to assess physicians' perceived outcome probabilities (both good and bad outcomes) for the target treatment. Type 1 surveys will assess judged outcome probabilities in the context of a representative patient, and include questions about how physicians currently treat such cases, the recollection of rare or vivid outcomes, as well as practice and demographic details. The primary goal of the Type 2 surveys is to measure the specific factors that drive individual clinical judgments and treatment decisions, using a 'clinical judgment analysis' or 'lens modeling' approach. This survey will manipulate eight clinical variables across a series of sixteen realistic case vignettes. Based on the survey responses, we will be able to identify which variables have the greatest effect on physician judgments, and whether judgments are affected by inappropriate cues or incorrect weighting of appropriate cues. We will send antibiotics surveys to family physicians (300 per survey), and warfarin surveys to both family physicians and internal medicine specialists (300 per group per survey), for a total of 1,800 physicians. Each Type 1 survey will be two to four pages in length and take about fifteen minutes to complete, while each Type 2 survey will be eight to ten pages in length and take about thirty minutes to complete. Discussion This work will provide insight into the extent to which clinicians' judgments about the likelihood of important treatment outcomes explain inappropriate treatment decisions. This work will also provide information necessary for the development of an individualized feedback tool designed to improve treatment decisions. The techniques developed here have the potential to be applicable to a wide range of clinical areas where inappropriate utilization stems from biased judgments.

Attempts to reform the US health care system in the 1980s and 1990s were inspired by the system's inability to adequately provide access, ensure quality, and restrain costs. In the era of managed care, after the Clinton administration's failed legislative effort at reform, access, quality, and costs are still problems, and medical professionals are increasingly dissatisfied. To aid understanding of why the system is now so dysfunctional, I have drawn upon discussions with thoughtful physicians about their direct experience. They raised important concerns not usually considered by health care reformers. Their central concern was about the abandonment of medicine's core values. They felt that health care has become dominated by large, bureaucratic organizations which may not honor these core values. Patients and physicians are often caught in conflicts between competing interests and demands. Those who work in health care may be subject to perverse incentives that discourage ethical practice. Health care leaders may be ill-informed, incompetent, self-interested, or even dishonest. Examples of attacks on the scientific basis of medicine have become more frequent. These worrying trends are not confined to the US. Physicians elsewhere should be skeptical of approaches to health care reform derived from the American model. European doctors should ensure the new health care initiatives do not undermine their core values or the best interests of their patients.

Most evidence guiding perioperative medical risk management of patients undergoing hip fracture repair focuses on cardiac and thromboembolic risk. Little is known of the relative clinical importance of other complications.To systematically map incidence and outcomes of a broad spectrum of medical complications after hip fracture repair.Retrospective cohort study of patients 60 years or older in 20 academic, community, and Veterans Affairs hospitals. Data on complications and mortality were abstracted from medical records by trained abstractors using standardized, pretested forms or the National Death Index.Of 8930 patients, 1737 (19%) had postoperative medical complications. Cardiac and pulmonary complications were most frequent (8% and 4% of patients, respectively). Similar numbers of patients had serious cardiac or pulmonary complications (2% and 3%, respectively). Other complications were gastrointestinal tract bleeding (2%), combined cardiopulmonary complications (1%), venous thromboembolism (1%), and transient ischemic attack or stroke (1%). Renal failure and septic shock were rare. After the index complication, 416 patients had 587 additional complications. Mortality was similar for serious cardiac or pulmonary complications (30 day: 22% and 17%, respectively; 1 year: 36% and 44%, respectively) and highest for patients with multiple complications (30 day: 29%-38%; 1 year: 43%-62%). Complications and death occurred significantly earlier for serious cardiac than for serious pulmonary complications (1 vs 4 days, 2 vs 8 days, P.001); length of stay for patients surviving these complications was similar.Most patients had no medical complications after hip fracture repair. Serious cardiac and pulmonary complications were equally important in frequency, mortality, and survivors' length of stay. Patients with multiple complications had especially poor prognosis.

BACKGROUND: Controversy exists regarding who should provide care for those with HIV/AIDS. While previous studies have found an association between physician HIV experience and patient outcomes, less is known about the relationship of physician specialty to HIV/AIDS outcomes or quality of care.

Background The impact of anesthetic choice on postoperative mortality and morbidity has not been determined with certainty. Methods The authors evaluated the effect of type of anesthesia on postoperative mortality and morbidity in a retrospective cohort study of consecutive hip fracture patients, aged 60 yr or older, who underwent surgical repair at 20 US hospitals between 1983 and 1993. The primary outcome was defined as death within 30 days of the operative procedure. The secondary outcomes were postoperative 7-day mortality, postoperative myocardial infarction, postoperative pneumonia, postoperative congestive heart failure, and postoperative change in mental status. Numerous comorbid conditions were controlled for individually and by several comorbidity indices using logistic regression. Results General anesthesia was used in 6,206 patients (65.8%) and regional anesthesia in 3,219 patients (3,078 spinal anesthesia and 141 epidural anesthesia). The 30-day mortality rate in the general anesthesia group was 4.4%, compared with 5.4% in the regional anesthesia group (unadjusted odds ratio = 0.80; 95% confidence interval = 0.66-0.97). However, the adjusted odds ratio for general anesthesia increased to 1.08 (0.84-1.38). The adjusted odds ratios for general anesthesia versus regional anesthesia for the 7-day mortality was 0.90 (0.59-1.39) and for postoperative morbidity outcomes were as follows: myocardial infarction: adjusted odds ratio = 1.17 (0.80-1.70); congestive heart failure: adjusted odds ratio = 1.04 (0.80-1.36); pneumonia: adjusted odds ratio = 1.21 (0.87-1.68); postoperative change in mental status: adjusted odds ratio = 1.08 (0.95-1.22). Conclusions The authors were unable to demonstrate that regional anesthesia was associated with better outcome than was general anesthesia in this large observational study of elderly patients with hip fracture. These results suggest that the type of anesthesia used should depend on factors other than any associated risks of mortality or morbidity.

Article-at-a-Glance Background Many interventions have been conducted to change physician behavior, but there is not much evidence regarding their effectiveness. A list of questions is proposed for those who would attempt such interventions: 1. Does the behavior (or decision making) need to be changed? This implies the next two questions. 1a. Is there a logical, evidence-based argument that one decision alternative is preferable for a particular situation? If the would-be behavior changer cannot make an evidence-based argument for changing behavior, there is little moral authority to intervene. 1b. Is there evidence that physicians are not choosing this decision alternative when they should? Interventions are often prompted by evidence that utilization of an alternative was too high or low, but physicians' decisions are not the only determinants of utilization. 2. What is the problem with the decision making? Common sense suggests that different problems require different solutions. Yet interventions are often pursued in the absence of clear information about the reasons physicians did not exhibit the preferred behavior. 3. How could the decision making best be changed? Finding the cognitive problems that caused "wrong" behavior should directly lead to the design of simple, targeted, effective interventions to change this behavior. The judgment and decision making psychology literature suggests that general instruction in reasoning and probability may improve judgments and decision processes. Summary Physicians' behavior appears to be resistant to change. Understanding why the behavior should be changed and what caused it may make the process of designing interventions more complicated. The resulting interventions, however, are more likely to be simple and successful.

To assess the attitudes of practicing general internists toward evidence-based medicine (EBM-defined as the process of systematically finding, appraising, and using contemporaneous research findings as the basis for clinical decisions) and their perceived barriers to its use.Cross-sectional, self-administered mail questionnaire conducted between June and October 1997.Canada.Questionnaires were sent to all 521 physician members of the Canadian Society of Internal Medicine with Canadian mailing addresses; 296 (60%) of 495 eligible physicians responded. Exclusion of two incomplete surveys resulted in a final sample size of 294.Mean age of respondents was 46 years, 80% were male, and 52% worked in large urban medical centers. Participants reported using EBM in their clinical practice always (33, 11%), often (173, 59%), sometimes (80, 27%), or rarely/never (8, 3%). There were no significant differences in demographics, training, or practice types or locales on univariate or multivariate analyses between those who reported using EBM often or always and those who did not. Both groups reported high usage of traditional (non-EBM) information sources: clinical experience (93%), review articles (73%), the opinion of colleagues (61%), and textbooks (45%). Only a minority used EBM-related information sources such as primary research studies (45%), clinical practice guidelines (27%), or Cochrane Collaboration Reviews (5%) on a regular basis. Barriers to the use of EBM cited by respondents included lack of relevant evidence (26%), newness of the concept (25%), impracticality for use in day-to-day practice (14%), and negative impact on traditional medical skills and "the art of medicine" (11%). Less than half of respondents were confident in basic skills of EBM such as conducting a literature search (46%) or evaluating the methodology of published studies (34%). However, respondents demonstrated a high level of interest in further education about these tasks.The likelihood that physicians will incorporate EBM into their practice cannot be predicted by any demographic or practice-related factors. Even those physicians who are most enthusiastic about EBM rely more on traditional information sources than EBM-related sources. The most important barriers to increased use of EBM by practicing clinicians appear to be lack of knowledge and familiarity with the basic skills, rather than skepticism about the concept.

Purpose: Utilization report cards are commonly used to assess hospitals. However, in practice, they rarely account for differences in patient populations among hospitals. Our study questions were: (1) How does transfusion utilization for hip fracture patients vary among hospitals? (2) What patient characteristics are associated with transfusion and how do those characteristics vary among hospitals? (3) Is the apparent pattern of variation of utilization among hospitals altered by controlling for these patient characteristics? Subjects and Methods: We included consecutive hip fracture patients aged 60 years or older who underwent surgical repair between 1982 and 1993 in 19 hospitals from four states, excluding those who refused blood transfusion, had multiple trauma, metastatic cancer, multiple myeloma, an above the knee amputation, or were paraplegic or quadriplegic. The outcome of interest was postoperative blood transfusion. "Trigger hemoglobin" was the lowest hemoglobin recorded before transfusion or recorded at any time during the week before or after surgery for patients who were not transfused. Results: There was considerable variation in transfusion among hospitals postoperatively (range 31.2% to 54.0%, P = 0.001). Trigger hemoglobin also varied considerably among hospitals. In unadjusted analyses, four of nine teaching and two of nine nonteaching hospitals had postoperative transfusion rates significantly higher than the reference (teaching) hospital, while one nonteaching hospital had a lower rate. In an analysis controlling for trigger hemoglobin and multiple clinical variables, one of nine teaching and four of nine nonteaching hospitals had rates higher than the reference hospital, while four teaching hospitals and one nonteaching hospital had lower rates. Conclusions: The apparent pattern of variation of transfusion among hospitals varies according to how one adjusts for relevant patient characteristics. Utilization report cards that fail to adjust for these characteristics may be mixleading.

Objective. Compare U.K. and U.S. physicians' judgments of population probabilities of important outcomes of invasive cardiac procedures; and values held by them about risk, uncertainty, regret, and justifiability relevant to utilization of cardiac treatments. Design. Cross-sectional study. Setting. University hospital and VA medical center in the United States; two teaching hospitals in the United Kingdom. Participants. 171 housestaff and attendings at U.S. teaching hospitals; 51 physician trainees and consultants at U.K. hospitals. Measures. Judgments of probabilities of severe complications and deaths due to Swan-Ganz catheterization, cardiac catheterization, percutaneous transluminal coronary angioplasty (PTCA), and coronary artery bypass grafting (CABG); judgments of malpractice risks for case vignettes; Nightingale's risk-aversion instrument; Gerrity's reaction-to-uncertainty instrument; questions about need to justify decisions; responses to case vignettes regarding regret. Results. The U.S. physicians judged rates of two bad outcomes of cardiac procedures (complications due to cardiac catheterization; death due to CABG) to be significantly higher (p ≤ 0.01) than did the U.K. physicians (U.S. medians, 5 and 3.5, respectively; U.K. medians 3 and 2). The median ratio of (risk of malpractice suit I error of omission)/(risk of suit I error of commission) judged by U.K. physicians, 3, was significantly (p = 0.0006) higher than that judged by U.S. physicians, 1.5. The U.K. physicians were less often risk-seeking in the context of possible losses than the U.S. physicians (odds ratio for practicing in the U.K. as a predictor of risk seeking 0.3, p = 0.003). The U.K. physicians had significantly more discomfort with uncertainty than did the U.S. physicians, as reflected by higher scores on the stress scale (U.K. median 48, U.S. 42, p = 0.0001) and the reluctance-to-disclose-uncertainty scale (U.K. 40, U.S. 37, p < 0.0001) of the Gerrity instrument. There was no clear international difference in perceived need to justify decisions, or in regret. Conclusions. The results were not clearly consistent with the uncertainty hypothesis that international practice variation is due to differences in judged rates of outcomes of therapy or with the imperfect-agency hypothesis that practice variation is due to differences in physicians' personal values. The causes and implications of practice variations remain unclear.

Qualitative research is becoming more prominent in medicine. It is still not clear how it can address either clinical or biopsychosocial research questions. Methodologic standards and guidelines for qualitative research in medicine and health care remain too sketchy to help one evaluate a qualitative study critically. Alternatives for addressing complex real-life questions quantitatively exist. Until better guidelines for qualitative research become available, we urge caution about using evidence from qualitative studies. Developments of such standards and guidelines are perhaps being hindered by continuing controversies among advocates of qualitative research about whether truth exists independent of its observer, and whether bias should be eliminated, disclosed, or actively encouraged. These controversies undermine the credibility of qualitative research for clinical and health services research audiences.

The authors compared judgments of the population risks of invasive cardiac procedures made by cardiologists and other internal medicine physicians. Our main hypotheses were that cardiologists' judgments would differ from those made by the other physicians and that cardiologists' judgments would be more accurate than those of other physicians.This was a cross-sectional survey of senior staff and physician-trainees at two teaching hospitals affiliated with a US medical school, Emergency Department physicians at a community hospital in the same metropolitan area, and senior staff and trainees at two teaching hospitals affiliated with a UK school. Judgments of the risks of severe morbidity and death due to Swan-Ganz catheterization, cardiac catheterization, percutaneous coronary angioplasty, and coronary artery bypass grafting were assessed.Nineteen cardiologists judged the risks of severe morbidity due to all procedures and the risks of death due to all procedures except coronary artery bypass grafting to be significantly lower than did the 78 other internists. Cardiologists more frequently made accurate judgments of the rates of morbidity and death due to cardiac catheterization than did the other internists; other internists more frequently made accurate judgments for the rates of morbidity due to Swan-Ganz catheterization.Disagreements about the risks of procedures may arise from a paucity of published data, or from an over-supply of confusing data.

Objectives. To determine whether improving physicians' judgments of the probability of streptococcal pharyngitis for patients with sore throats would affect their use of antibiotics and affect the variation in such use. Design. Post-hoc retrospective analysis of data previously collected as part of a controlled trial. Settings. University student health services in Penn sylvania and Nebraska. Patients. Sequential patients with pharyngitis seen before and after the time clinicians received either an experimental educational intervention designed to improve probabilistic diagnostic judgments (at the Pennsylvania site) or a control intervention, a standard lecture (at the Nebraska site). The clinician-subjects were the primary case physicians practicing at either site. Measurements. Clinical variables prospectively recorded by the clinicians, probability assessments, and treatment decisions. Results. At the experi mental site, despite marked decreases in clinicians' overestimations of disease probability after the intervention, the proportion of patients prescribed antibiotics showed a trend toward increasing: 100/290 (34.5%) pre-intervention, 90/225 (40%) post-intervention. The interven tion did not decrease practice variation between individual doctors. Univariable and multi variable analyses showed no major change in the relationships between clinical variables and treatment decisions after the intervention. At the control site there was no major change in probability judgments or treatment decisions after the intervention. Conclusions. Teaching physicians to make better judgments of disease probability may not alter their treatment decisions. Key words: knowledge; probability; decision making; pharyngitis diagnosis. (Med Decis Making 1995;15:65-75)

Anticipation of regret for choosing the wrong option may directly affect physicians' choice of treatment. As part of a pilot survey of physician practices for agitated dementia patients, we asked geriatric psychiatrists, primary care physicians, and neurologists to estimate the degree of anticipated regret that they might experience in response to a series of brief case vignettes describing typical treatments and outcomes for agitated dementia patients. Eight written vignettes described physician action (ordering vs. not ordering), type of intervention (haloperidol vs. physical restraints), and outcome of the intervention (adverse patient outcome vs. adverse staff outcome). Regret was measured by using a five-point Likert scale. A full factorial regression model found that "not ordering" actions were associated with more regret than "ordering" actions, regardless of specialty, intervention, or outcome. Also, geriatric psychiatrists, compared with the other physician groups, expressed the least regret for ordering (and the most for not ordering) haloperidol.

Source Citation Schjerning Olsen AM, Fosbol EL, Lindhardsen J, et al. Duration of treatment with nonsteroidal anti-inflammatory drugs and impact on risk of death and recurrent myocardial infarction...

The objective of this study was to assess whether geographic differences in antibiotic- prescribing rates for patients with pharyngitis could be explained by intersite differences in patients' clinical characteristics and in how physicians responded to these clinical cues when making decisions. As part of the initial phase of a prospective controlled trial to improve physicians' diagnostic ability, the authors enrolled cohorts of consecutive patients seen at staff-model-HMO student health services in Pennsylvania and Nebraska. Physicians' de cisions whether to prescribe antibiotics for 310 consecutive patients presenting with phar yngitis to the former and 214 such patients presenting to the latter at the time of the initial visit were examined. There was a large discrepancy between the antibiotic-prescribing rates at the student health services in Pennsylvania, 106/310, 32.4%, and Nebraska, 156/214, 72.9%. The clinical variables significantly independently associated with treatment at both sites in a logistic regression model were fever, adjusted odds ratio = 2.1 (95% Cl = 1.1, 3.8); exudates, 5.4 (2.8, 10); palatine petechiae, 6.5 (1.5, 28); rhinorrhea, 0.46, (0.25, 0.85); and high risk of complications, 3.8 (1.04, 14). There was a significant interaction between site and anterior cervical adenopathy, 5.5 (1.6, 19); and a borderline interaction between site and rhinorrhea, 2.4 (0.89, 6.7). Site was not a significant independent predictor of treatment, 1.8 (0.45, 6.6.). Practice variation was related to geographic differences in patients' clinical characteristics and in how physicians responded to these factors when prescribing antibiotics. How physicians weight patients' clinical characteristics when making decisions may be an important element of their "practice styles." Key words: geographic variation; prescription decisions; physicians' practice styles; pharyngitis. (Med Decis Making 1993;13:293-301)

The efforts of the U.S. Preventive Service TaskForce (USPSTF) to keep their evidence-based guidelines up to dateare praiseworthy. It is understandable that practical concerns maylimit specific questions addressed by new literature reviews. None-theless, it is disappointing that the questions addressed in the recentupdate of the depression screening guidelines (1) were not broader.In particular, the narrowly defined review did not consider new ev-idence on the efficacy of antidepressant treatment of depression from2 recent meta-analyses, which included many clinical trials whoseresults were not published and were heretofore inaccessible.Turner and colleagues (2) showed that results of 31% of com-pleted trials registered with the U.S. Food and Drug Administration(FDA) for 12 antidepressant drugs were provided to the FDA butnot published. Of these 23 unpublished trials, 16 did not showsignificant efficacy per FDA review. Meta-analysis of all trials, pub-lished and unpublished, showed that antidepressants were less effica-cious than in meta-analyses of only published trials. Furthermore,Kirsch and colleagues’ meta-analysis (3) of published and unpub-lished trials of 6 antidepressants, all of which provided results interms of the Hamilton Rating Scale for Depression, showed that thedrugs’ effects were barely clinically significant. Thus, these 2 meta-analyses showed that failure to publish an important minority of“negative” trials of antidepressants biased the published literature infavor of these drugs, and that this bias made the drugs seem moreefficacious than they really are. If these widely touted treatments ofdepression are really of marginal clinical effectiveness, the rationalefor screening for depression comes into question.Furthermore, the increasing number of cases in which clinicalresearch results that did not favor the interests of the commercialsponsors of the studies were suppressed suggests that we need torethink how evidence is gathered to support evidence-based practiceguidelines and perhaps how we regulate clinical research. A recenteditorial (4) in response to concerns about manipulating and sup-pressing evidence noted that “...thecurrent system isn’t working.Worse than that, it gives a false sense of security. The system’s fail-ures have left a legacy of drug evaluations for which, in the absenceof better information, we must assume...confusion and uncer-tainty...”.Failure to consider these issues when developingevidence-based guidelines just boots the problem down the road forothers to solve after it has become even more pernicious.

To assess the patient and physician characteristics that influence physicians' detection of problem drinking in their medical patients.The outpatient medical clinic at an urban university teaching hospital staffed by interns and residents.Cross-sectional study of a randomly chosen subsample of consecutive patients.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).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.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.

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.

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.Pre- and postintervention study.All medical services in a university teaching hospital.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.Incorporation of a predischarge reminder for pneumococcal vaccination in the hospital information system.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.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.

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.

To clarify the widespread practice of preoperative transfusion to attain a 10 g/dL level of hemoglobin, the relationship between preoperative hemoglobin level, operative blood loss, and mortality was studied by analyzing the results of 113 operations in 107 consecutive Jehovah's Witness patients who underwent major elective surgery. Ninety-three patients had preoperative hemoglobin values greater than 10 g/dL; 20 had preoperative hemoglobin levels between 6 to 10 g/dL. Mortality for preoperative hemoglobin levels greater than 10 g/dL was 3 of 93 (3.2%); for preoperative hemoglobin levels between 6 to 10 g/dL, mortality was 1 of 20 (5%). Mortality was significantly increased with an estimated blood loss of greater than 500 mL, regardless of the preoperative hemoglobin level (p less than 0.025). More importantly, there was no mortality if estimated blood loss was less than 500 mL, regardless of the preoperative hemoglobin level. From these data, we conclude that: (1) Mortality in elective surgery appears to depend more on estimated blood loss than on preoperative hemoglobin levels; and (2) Elective surgery can be done safely in patients with a preoperative hemoglobin level as low as 6 g/dL if estimated blood loss is kept below 500 mL.

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

Context Elderly patients are at high risk of both abnormal hematocrit values and cardiovascular complications of noncardiac surgery. Despite nearly universal screening of patients for abnormal preoperative hematocrit levels, limited evidence demonstrates the adverse effects of preoperative anemia or polycythemia. Objective To evaluate the prevalence of preoperative anemia and polycythemia and their effects on 30-day postoperative outcomes in elderly veterans undergoing major noncardiac surgery. Design Retrospective cohort study using the VA National Surgical Quality Improvement Program database. Based on preoperative hematocrit levels, we stratified patients into standard categories of anemia (hematocrit 39.0%), normal hematocrit (39.0%-53.9%), and polycythemia (hematocrit 54%). We then estimated increases in 30-day postoperative cardiac event and mortality risks in relation to each hematocrit point deviation from the normal category. Setting and Patients A total of 310 311 veterans aged 65 years or older who underwent major noncardiac surgery between 1997 and 2004 in 132 Veterans’ Affairs medical centers across the United States. Main Outcome Measures The primary outcome measure was 30-day postoperative mortality; a secondary outcome measure was composite 30-day postoperative mortality or cardiac events (cardiac arrest or Q-wave myocardial infarction). Results Thirty-day mortality and cardiac event rates increased monotonically, with either positive or negative deviations from normal hematocrit levels. We found a 1.6% (95% confidence interval, 1.1%-2.2%) increase in 30-day postoperative mortality associated with every percentage-point increase or decrease in the hematocrit value from the normal range. Additional analyses suggest that the adjusted risk of 30-day postoperative mortality and cardiac morbidity begins to rise when hematocrit levels decrease to less than 39% or exceed 51%. Conclusions Even mild degrees of preoperative anemia or polycythemia were associated with an increased risk of 30-day postoperative mortality and cardiac events in older, mostly male veterans undergoing major noncardiac surgery. Future studies should determine whether these findings are reproducible in other populations and if preoperative management of anemia or polycythemia decreases the risk of postoperative mortality. JAMA. 2007;297:2481-2488 www.jama.com