The influence of types of decision support on physicians' decision making

Abstract

Objective: To determine whether physicians’ posttest probability estimates are influenced by receiving test characteristics and impact their subsequent clinical decisions.

Design: Questionnaire-based randomized controlled trial.

Setting: Mailed survey with a vignette describing an infant whose pretest likelihood of pertussis was 30% and direct fluorescent-antibody (DFA) test was negative for pertussis.

Subjects: Nationally representative sample of U.S. pediatricians (N = 1502).

Interventions: Random receipt of either: 1) no additional information (controls); 2) the DFA’s sensitivity & specificity (TC group); or 3) the test’s sensitivity & specificity with their definitions (TCD group).

Main Outcome Measures: Estimated posttest probability (PTP) of pertussis; PTP of 0.50; “nearly correct” PTP (correct PTP ± 5%).

Analyses: Chi-square and t-tests.

Results: With 635 participants, the survey’s estimated response rate was 49.7%. Despite the negative DFA result, 67% of participants estimated a PTP higher than the pretest probability of 30% (mean PTP = 0.41; SD ±0.26). The mean PTP of the TCD group was significantly higher than controls (0.45 vs. 0.38, p<0.001), while those of TC and controls did not differ significantly (0.41 vs. 0.38, p = 0.16). Decision support had 2 distinct effects on participants; compared to controls, significantly more TC and TCD participants estimated the PTP to be 0.50 (38% vs. 17%, p<0.0005; 41% vs. 17%, p<0.0005), and also estimated a nearly correct PTP more often (20% vs. 13%, p=0.06; 19% vs. 13%, p=0.08, respectively).

Conclusions: Receiving information about test characteristics increased errors in post-test probability estimation for many pediatricians, while it reduced errors for others.