Effect of two behavioural 'nudging' interventions on management decisions for low back pain: A randomised vignette-based study in general practitioners

Objective €Nudges' are subtle cognitive cues thought to influence behaviour. We investigated whether embedding nudges in a general practitioner (GP) clinical decision support display can reduce low-value management decisions. Methods Australian GPs completed four clinical vignettes of patients with low back pain. Participants chose from three guideline-concordant and three guideline-discordant (low-value) management options for each vignette, on a computer screen. A 2×2 factorial design randomised participants to two possible nudge interventions: €partition display' nudge (low-value options presented horizontally, high-value options listed vertically) or €default option' nudge (high-value options presented as the default, low-value options presented only after clicking for more). The primary outcome was the proportion of scenarios where practitioners chose at least one of the low-value care options. Results 120 GPs (72% male, 28% female) completed the trial (n=480 vignettes). Participants using a conventional menu display without nudges chose at least one low-value care option in 42% of scenarios. Participants exposed to the default option nudge were 44% less likely to choose at least one low-value care option (OR 0.56, 95%CI 0.37 to 0.85; p=0.006) compared with those not exposed. The partition display nudge had no effect on choice of low-value care (OR 1.08, 95%CI 0.72 to 1.64; p=0.7). There was no interaction between the nudges (OR 0.94, 95% CI 0.41 to 2.15; p=0.89). Interpretation A default option nudge reduced the odds of choosing low-value options for low back pain in clinical vignettes. Embedding high value options as defaults in clinical decision support tools could improve quality of care. More research is needed into how nudges impact clinical decision-making in different contexts

A Fit between Clinical Workflow and Health Care Information Systems: Not waiting for Godot but making the journey

Health care has long suffered from inefficiencies due to the fragmentation of patient care information and the lack of coordination between health professionals [1]. Health care information systems (HISs) have been lauded as tools to remedy such inefficiencies [2, 3]. The primary idea behind the support of their implementation in health care is that these systems support clinical workflow and thereby decrease medical errors [2]. However, their introduction to health care settings have been accompanied by a transformation of the way their primary users, care providers, carry out clinical tasks and establish or maintain work relationships [4]. Studies have shown that these transformations have not always been productive [5, 6]

A review of human factors principles for the design and implementation of medication safety alerts in clinical information systems.

The objective of this review is to describe the implementation of human factors principles for the design of alerts in clinical information systems. First, we conduct a review of alarm systems to identify human factors principles that are employed in the design and implementation of alerts. Second, we review the medical informatics literature to provide examples of the implementation of human factors principles in current clinical information systems using alerts to provide medication decision support. Last, we suggest actionable recommendations for delivering effective clinical decision support using alerts. A review of studies from the medical informatics literature suggests that many basic human factors principles are not followed, possibly contributing to the lack of acceptance of alerts in clinical information systems. We evaluate the limitations of current alerting philosophies and provide recommendations for improving acceptance of alerts by incorporating human factors principles in their design

Master of Science

thesisCampylobacteriosis is a foodborne and waterborne zoonotic gastrointestinal illness and the most common cause of acute gastroenteritis worldwide. In the United States Campylobacter infections are second only to Salmonella as the most common cause of gastroenteritis, accounting for an estimated 2.4 million symptomatic infections annually. It is estimated that the total cost of foodborne illness in the United States is $152 billion of which$18.8 billion is attributed to Campylobacter. Diagnosis can be challenging because the organism is difficult to isolate, grow, and identify. Clinical manifestation of Campylobacter is indistinguishable from other enteric pathogens; (Salmonella, Shigella, Yersinia, Clostridium difficile, and E. coli 0157:H7 and other enterohemorrhagic E. coli) therefore, a presumptive diagnosis cannot be made putting them at risk for untreated infection. There are a growing number of diagnostic methods available for detection and/or isolation of Campylobacter species from stool, but there is currently no national or state public health testing guidelines. Eight assays were evaluated for performance in the detection of Campylobacter species in stool. The assays are comprised of four culture medias (CVA, CSM, Cefex, and mCCDA); three EIA/ELISA kits (ImmunoCard STAT! Campy, Premier Campy and ProSpecT Campy); and one molecular method (FilmArray GI panel). The FilmArray GI panel due to its ability to detect viable and nonviable organism was used as the gold standard. To verify the gold standard was accurate all positive FilmArray samples were analyzed by DNA sequencing. The sensitivity and specificity, respectively, of each assay are as follows: CVA 87.8%, 100%; CSM 87.8%, 100%; Cefex 87.8%, 100%; mCCDA 78.0%, 100%; ImmunoCard STAT! Campy 31.7%, 65.2%; Premier Campy 80.5%, 26.1%; and the ProSpecT Campy 75.6%, 82.6%. In contrast the FilmArray produces a sensitivity and specificity of 100% when compared to culture. Furthermore the FilmArray GI panel takes the least amount of time to produce a result, 1 hour compared to 48-72 hours for culture. In conclusion, the FilmArray GI panel is the most sensitive, specific, rapid, cost effective, and objective method for the detection of Campylobacter species in stool. Molecular assays such as the FilmArray GI panel should replace traditional culture techniques in the microbiology lab

Understanding Advice Sharing among Physicians: Towards Trust-Based Clinical Alerts

Safe prescribing of medications relies on drug safety alerts, but up to 96% of such warnings are ignored by physicians. Prior research has proposed improvements to the design of alerts, but with limited increase in adherence. We propose a different perspective: before re-designing alerts, we focus on improving the trust between physicians and computerized advice by examining why physicians trust their medical colleagues. To understand trusted advice among physicians, we conducted three contextual inquiries in a hospital setting (22 participants), and corroborated our findings with a survey (37 participants). Drivers that guide physicians in trusting peer advice include: timeliness of the advice, collaborative language, empathy, level of specialization and medical hierarchy. Based on these findings, we introduce seven design directions for trust-based alerts: endorsement, transparency, team sensing, collaborative, empathic, conflict mitigating and agency laden. Our work contributes to novel alert design strategies to improve the effectiveness of drug safety advice

COMBINING HUMAN FACTORS AND DATA SCIENCE METHODS TO EVALUATE THE USE OF FREE TEXT COMMUNICATION ORDERS IN ELECTRONIC HEALTH RECORDS

Medication errors are a leading cause of death in the United States. Electronic Health Records (EHR) along with Computerized Provider Order Entry (CPOE) are considered promising ways to reduce these errors. However, EHR systems have not eliminated medication errors. Moreover, in some cases they have facilitated errors due to issues such as poor usability and negative effects on clinical workflows. The use of unexpected free text within a CPOE system can serve as a marker that the system does not adequately support clinical workflow. Prior studies have looked at the use of free text within medication orders, but the inclusion of medication related information in communication for non-medication orders (CNMOs), a type of free text order, has not been adequately studied. This mixed-methods study identified the prevalence, nature and reasons for the inclusion of medication related information in CNMOs using a large sample of CNMOs placed at a mid-Atlantic hospital system in 2017, and via interviews with physicians. The study found that more than 42% of CNMOs contain medication related information. Moreover, the use of CNMOs varied significantly across provider types, hospital locations, patient settings and other factors. The study found 10 themes that might cause providers to adopt such workarounds, including missing functionality and poor usability. The viii study also identified several general challenges in communicating medication information in the EHR, and potential solutions to mitigate these challenges. This dissertation also demonstrates how natural language processing could be used to identify medication related CNMOs

Attitudes on Medical Ethics of Criminal Neurointerventional Treatment

As contemporary scientific advancements offer the opportunity to manipulate processes of the human body at a higher degree of invasiveness than ever before, a number of bioethical concerns are raised. One significant concern is how to discern the acceptable integration of advancements in neurologically-based interventions into the criminal justice system. Past literature supports the idea that there are several variables that interact to form a global conversation on the ethics of compromising a criminal’s freedom of mind for the purposes of sentencing or rehabilitation. Attitudes toward the current criminal justice system and the current uses of neurointerventions are significantly influential, and the public attitudes of such topics have been well-recorded through the literature. An experienced physician was interviewed in order to gain the perspective of a professional who regularly implements neurologically-based treatments. The results of the interview suggested that professionals have a moderate level of confidence that the current relationship between the criminal justice system and neurointerventional methods has generally remained within ethical boundaries. The results also suggested that medical practitioners are tasked with balancing the dignity and the safety patients, which can cause frequent ethical dilemmas. The varying responsibilities of medical professionals keep them equipped to implement expert-level care while simultaneously considering the ethical ramifications of their decisions

Functional Status in the Young-Old: Establishing a Working Prototype of an Extended-Instrumental Activities of Daily Living Scale

BACKGROUND: Instrumental activities of daily living (IADLs) exhibit strong predictive power for the presence of dementia and mild cognitive impairment. However, IADLs are often less effective in younger cohorts or in healthy community-dwelling samples, presenting with large ceiling effects. This study aimed to construct an IADL scale with an extended range. An effort was made to incorporate leisure activity tasks that were more stimulating, and potentially more challenging, into a set of traditional IADLs. METHODS: Beginning with a set of IADL and leisure activity items, nonparametric item response theory methodology was used to construct a scale with appropriate dimensionality, monotonicity, item discrimination power, and scalability within a large cohort of young-old (aged 65-75). Dimensionality was further scrutinized by principal component analysis of the residuals. The predictive validity of the resulting scale for poor cognitive performance was evaluated using logistic regression. RESULTS: A reliable (rho = .73) unidimensional construct was established, meeting the Mokken item response theory criteria of medium scalability. Excluding demented participants, the adjusted model proved sensitive to relatively subtle cognitive deficits; each additional task endorsed (nine-item scale) significantly decreased the odds of being in the bottom quarter of composite domains relating to processing speed (odds ratio = 0.73 [confidence interval: 0.56-0.97], p < .05) and visuospatial ability (odds ratio = 0.70 [confidence interval: 0.73-0.87], p < .01). CONCLUSIONS: A reliable extended-IADL scale was constructed meeting item response theory assumptions relating to unidimensionality, monotonicity, and invariant item ordering. The range of measurement extends well beyond traditional IADL scales. Finally, the scale appears to be sensitive to cognitive differences within the normal spectrum