Variability of the impact of adverse events on physicians' decision making.

BACKGROUND: Physicians frequently differ in their treatment recommendations. However, few studies have examined the reasons underlying these differences. The objective of this study was to examine whether physicians vary in the importance they attach to specific adverse events for two treatment options found in recent randomized controlled trials to have equivalent efficacy and overall toxicity. METHODS: A Max-Diff survey was administered to physicians attending a national scientific conference to quantify the influence of 23 specific adverse events on decision making related to two treatment options for vasculitis. This approach was chosen because it results in greater item discrimination compared to rating scales. We used Hierarchical Bayes modeling to generate the relative importance score for each adverse event and examined the association between physicians' characteristics and the five most influential factors. RESULTS: 118 physicians completed the survey. The mean age (SD) was 48 years (10); 68% were male and 81% reported spending the majority of time in clinical practice. There was significant variability in the ratings of the relative importance of all adverse events, except those that were mild and easily reversible. We found a positive correlation between increasing physician age with ratings of sepsis (r = 0.29, p = 0.002) and opportunistic infection (r = 0.23, p = 0.016), and an inverse association between age with progressive multifocal leukoencephalopathy (r = - 0.28, p = 0.003). Physician sex, work setting, location, and number of patients with vasculitis seen per year were not associated with the influence of specific adverse events on decision making. CONCLUSION: Our findings demonstrate that physicians differ substantially in how they perceive the importance of specific adverse events which may help explain observed unwarranted variability in physicians' recommendations in clinical practice. Further efforts are needed to ensure that the reasons underlying variability in physicians' recommendations are transparent.

Variability in experts' opinions regarding risks and treatment choices in patients with antineutrophil cytoplasmic antibody-associated vasculitis.

OBJECTIVE: There are insufficient toxicity data available to guide treatment decisions in patients with ANCA (antineutrophil cytoplasmic antibody)-associated vasculitis. The objective of this study was to obtain expert input related to available treatment options. METHODS: We performed a Web-based survey of experts (defined as physicians whose practices focus on vasculitis and physicians engaged in research in vasculitis) regarding adverse events (AEs) associated with cyclophosphamide and/or rituximab, the 2 treatment options for remission induction of severe ANCA-associated vasculitis (AAV). Using scaled measures, experts rated (i) the probability of 30 AEs associated with the treatments and (ii) the importance of disclosing each AE and reported (iii) their treatment preferences using standardized scenarios. RESULTS: Ratings of the probabilities of specific AEs associated with cyclophosphamide and rituximab varied significantly among the experts. The majority agreed that AEs related to fertility, infections, and serious infusion reactions were "extremely" or "very important" to disclose. Less than half of the experts surveyed endorsed disclosing the risks of progressive multifocal leukoencephalopathy, hepatitis reactivation, or zoster. For patients with newly diagnosed AAV, the majority of experts preferred intravenous cyclophosphamide for older adults and rituximab for younger women with newly diagnosed AAV. For patients with recurrent disease who had been previously treated with cyclophosphamide, the majority of experts preferred rituximab, regardless of age or sex. CONCLUSIONS: The variability noted in this study suggests that the information and treatment patients receive may differ depending on where they receive their care. This type of unwarranted variability could be reduced if data from long-term extension and observational studies generate more precise outcome estimates for treatment-related AEs in AAV.

Improving the Combination Pneumococcal Vaccination Rate in Systemic Lupus Erythematosus Patients at an Adult Rheumatology Practice.

OBJECTIVE: The risk of developing invasive pneumococcal infection is 13 times higher in patients with systemic lupus erythematosus (SLE) in comparison with the general population. The US Centers for Disease Control and Prevention anticipates a US$7.6 million medical cost reduction by providing pneumococcal vaccination. The objective of this study was to improve the rate of combination pneumococcal vaccination (pneumococcal polysaccharide vaccine 23 + pneumococcal conjugate vaccine 13) in patients with SLE in our adult academic rheumatology practice. METHODS: With the use of physician- and staff-based surveys, we analyzed the underlying barriers in providing vaccination. We then planned a multifaceted intervention including pre-visit planning, day-of-visit planning, weekly review, and monthly feedback. RESULTS: Our project is one of the few studies planned to improve combination pneumococcal vaccination rates in adult patients with SLE and we report an impressive improvement from 10% baseline rate to 59% vaccination rate by the end of the study period. This highlights the role of planning an intervention with an integrated workflow and the importance of sharing performance data, which leads to high compliance among team members. CONCLUSION: The significant improvement in combination vaccination rate in eligible patients with SLE and the additional rise of vaccine rates seen in other eligible patients in the practice draws attention to the high adaptiveness of the intervention resulting in a true practice change. Our quality project design can serve as a model that can be adapted by other specialty clinics to achieve higher vaccination standards.

Influence of Explanatory Images on Risk Perceptions and Treatment Preference.

OBJECTIVE: The aim of this study was to examine whether providing patients with a series of balance scales (BS), depicting a reciprocal relationship between achieving disease control and increasing the risk of infection, influences treatment preference. METHODS: Participants were randomized to receive a description of a medication in which risk of infection was relayed using 1 of 4 formats, including numbers only, numbers + icon array (IA), numbers + BS, or numbers + IA + BS (i.e., combination). We compared the likelihood of starting the medication across the 4 formats, and evaluated whether the influence of risk formats varied by numeracy and gist risk appraisals. RESULTS: The mean ± SE likelihood of starting the medication was higher among participants randomized to the combination format (3.85 ± 0.09) compared to those who viewed the BS (3.56 ± 0.09; P = 0.0222) or numbers-only formats (3.51 ± 0.09; P = 0.0069). Viewing an IA alone was associated with a lower likelihood of starting the medication among participants lower in numeracy and endorsing a risk-avoidant noncompensatory gist risk appraisal. Conversely, viewing an IA (with or without the BS) was associated with a greater likelihood of starting the medication among patients with higher numeracy and compensatory risk appraisals. CONCLUSION: Adding explanatory images to IAs increases patient likelihood to take a medication in those with low numeracy and a noncompensatory gist risk appraisal. Explanatory images may be a feasible approach to improve willingness to try medication among subjects who are especially risk averse and believe that any risk is unacceptable.

Do visual aids influenced patients' risk perceptions for rare and very rare risks?

OBJECTIVE: To examine whether visual aids (a graphic representation and/or conceptual illustrations) influence patients' risk perceptions for rare and very rare risks. METHODS: Participants were randomized to a scenario which varied by probability of infection (2% or 0.2%) and visual aid: numbers only, numbers + graphic representation, numbers + conceptual illustrations, or numbers + graphic representation + conceptual illustrations. Risk perceptions and likelihood of starting the medication were examined across the four formats, separately, in participants with and without a college education. RESULTS: Adding a graphic representation and/or conceptual illustrations did not affect risk perceptions among those with a higher level of education. Adding both a graphic representation + conceptual illustrations decreased risk perceptions and increased likelihood of starting the medication among participants randomized to the 2%, but not 0.2% scenario, among participants with lower levels of education. CONCLUSION: Adding a graphic representation + conceptual illustrations to numbers may influence perceptions for rare, but not very rare, risks among patients with lower education. PRACTICE IMPLICATIONS: Clinicians should be aware of the differential effects of visual aids developed to facilitate risk communication. Patients with higher levels of education may be less responsive to visual aids than those with lower education.