Assessing the impact of colonoscopy complications on use of colonoscopy among primary care physicians and other connected physicians: an observational study of older Americans

Abstract

ObjectivesPsychological biases can distort treatment decision-making. The availability heuristic is one such bias, wherein events that are recent, vivid or easily imagined are readily ‘available’ to memory and are therefore judged more likely to occur than expected based on epidemiological data. We assessed if the occurrence of a serious colonoscopy complication for a primary care physician’s patient influenced colonoscopy rates for the physician’s other patients.DesignLongitudinal study with time-varying exposure variables.Setting/participantsIndividuals living in 51 hospital referral regions across the USA identified based on enrolment in fee-for-service Medicare during 2005–2010. We assigned patients to a primary care physician based on office visits during the prior 2 years.ExposuresFor each physician in each month, we calculated the proportion of patients assigned to them who had a colonoscopy. We identified two serious complications of which the primary care provider would very likely be aware: gastrointestinal bleed or perforation leading to hospitalisation or death within 14 days of colonoscopy.Main outcome measuresWe employed Poisson regression models including physician fixed effects to assess the change in number of colonoscopies in the four quarters following an adverse colonoscopy event.ResultsWe identified 5 360 191 patients assigned to 30 704 physicians. 4864 physicians (16%) had at least one patient with an adverse event. The estimated change in the quarterly number of colonoscopies among physicians’ patients was significantly lower in quarter 2 following an adverse colonoscopy event (change=−2.1% (95% CI −3.4 to −0.8%)), before returning to the rate expected in the absence of an adverse event.ConclusionsHaving a patient experience a serious adverse colonoscopy event was associated with a small and temporary decline in colonoscopy rates among a physician’s other patients. This finding provides empirical evidence for the influence of notable adverse events on care, possibly due to the availability heuristic.

Heuristics in the delivery room

“…This behavior can be, for example, loosely predicted by a “win-stay/lose-shift” heuristic, according to which the decision-maker either switches strategies if the last outcome was a “loss” or continues with the same strategy if the last outcome was a “win.” The use of this heuristic has been observed in animals ( 5 ), lay individuals ( 6 , 7 ), and experts in domains such as medicine. For instance, physicians appear to “shift” strategies after a “loss”: Incurring a complication due to a drug reduces usage of the drug ( 8 , 9 ); having malpractice concerns or missed diagnoses subsequently increases clinical testing ( 10 – 12 ). Of course, these patterns can be also predicted by other closely related theories of heuristics and decision-making, such as availability ( 13 , 14 ), salience ( 15 ), recency ( 16 ), and attribute substitution ( 17 , 18 ).…”

“…The use of this heuristic has been observed in animals (5), lay individuals (6,7), and experts in domains such as medicine. For instance, physicians appear to "shift" strategies after a "loss": Incurring a complication due to a drug reduces usage of the drug (8,9); having malpractice concerns or missed diagnoses subsequently increases clinical testing (10)(11)(12). Of course, these patterns can be also predicted by other closely related theories of heuristics and decisionmaking, such as availability (13,14), salience (15), recency (16), and attribute substitution (17,18).…”

Changes in Cancer Screening Rates Following a New Cancer Diagnosis in a Primary Care Patient Panel

“…Consistent with previous literature, we used the first new cancer diagnosis in the study period as the exposure of interest for PCPs with multiple new cancer diagnoses. 33 , 34 , 35 , 36 , 37 …”

“… 28 , 29 , 30 , 31 For example, a 2018 randomized trial 32 of letters notifying physicians of opioid overdoses in patients to whom they prescribed opioids demonstrated a sharp decrease in prescribing. Additional studies 33 , 34 , 35 , 36 , 37 on adverse clinical events, such as gastrointestinal bleeding, pulmonary embolism diagnoses, and unexpected newborn deaths, have found associations between such events and downstream changes in physicians’ clinical decisions. It is plausible that a new cancer diagnosis could increase cancer screening rates through similar behavioral mechanisms.…”

DNA methylation detection methods used in colorectal cancer

“…Furthermore, colonoscopies and polypectomies are complicated technical procedures that require training and experience to maximize accuracy and safety[9]. In addition, the procedures for tests such as colonoscopies are not acceptable to all individuals and can have complications[10,11]. Future research and further investigations aiming to identify predictive biomarkers can be generally useful in developing available, noninvasive, cost-effective diagnostic and prognostic panels that would have immense societal benefits[12].…”