Ramos João Gabriel Rosa, Ranzani Otavio Tavares, Dias Roger Daglius, Forte Daniel Neves
Clínica Florence - Salvador (BA), Brasil.
Unidade de Terapia Intensiva, Hospital São Rafael, Rede D'Or São Luiz - Salvador (BA), Brasil.
Rev Bras Ter Intensiva. 2021 Apr-Jun;33(2):219-230. doi: 10.5935/0103-507X.20210029.
To assess the impact of intensive care unit bed availability, distractors and choice framing on intensive care unit admission decisions.
This study was a randomized factorial trial using patient-based vignettes. The vignettes were deemed archetypical for intensive care unit admission or refusal, as judged by a group of experts. Intensive care unit physicians were randomized to 1) an increased distraction (intervention) or a control group, 2) an intensive care unit bed scarcity or nonscarcity (availability) setting, and 3) a multiple-choice or omission (status quo) vignette scenario. The primary outcome was the proportion of appropriate intensive care unit allocations, defined as concordance with the allocation decision made by the group of experts.
We analyzed 125 physicians. Overall, distractors had no impact on the outcome; however, there was a differential drop-out rate, with fewer physicians in the intervention arm completing the questionnaire. Intensive care unit bed availability was associated with an inappropriate allocation of vignettes deemed inappropriate for intensive care unit admission (OR = 2.47; 95%CI 1.19 - 5.11) but not of vignettes appropriate for intensive care unit admission. There was a significant interaction with the presence of distractors (p = 0.007), with intensive care unit bed availability being associated with increased intensive care unit admission of vignettes inappropriate for intensive care unit admission in the distractor (intervention) arm (OR = 9.82; 95%CI 2.68 - 25.93) but not in the control group (OR = 1.02; 95%CI 0.38 - 2.72). Multiple choices were associated with increased inappropriate allocation in comparison to the omission group (OR = 5.18; 95%CI 1.37 - 19.61).
Intensive care unit bed availability and cognitive biases were associated with inappropriate intensive care unit allocation decisions. These findings may have implications for intensive care unit admission policies.
评估重症监护病房床位可用性、干扰因素及选择框架对重症监护病房收治决策的影响。
本研究是一项使用基于患者的病例 vignettes 的随机析因试验。经一组专家判断，这些 vignettes 被视为重症监护病房收治或拒绝的典型案例。重症监护病房医生被随机分为 1）干扰增加组（干预组）或对照组，2）重症监护病房床位稀缺或不稀缺（可用性）环境组，以及 3）多项选择或遗漏（现状）vignette 情景组。主要结局是适当的重症监护病房分配比例，定义为与专家小组做出的分配决策一致。
我们分析了 125 名医生。总体而言，干扰因素对结局无影响；然而，存在不同的退出率，干预组完成问卷的医生较少。重症监护病房床位可用性与被认为不适合重症监护病房收治的 vignettes 的不适当分配相关（OR = 2.47；95%CI 1.19 - 5.11），但与适合重症监护病房收治的 vignettes 无关。与干扰因素的存在存在显著交互作用（p = 0.007），在干扰（干预）组中，重症监护病房床位可用性与被认为不适合重症监护病房收治的 vignettes 的重症监护病房收治增加相关（OR = 9.82；95%CI 2.68 - 25.93），而在对照组中则不然（OR = 1.02；95%CI 0.38 - 2.72）。与遗漏组相比，多项选择与不适当分配增加相关（OR = 5.18；95%CI 1.37 - 19.61）。
重症监护病房床位可用性和认知偏差与不适当的重症监护病房分配决策相关。这些发现可能对重症监护病房收治政策有影响。
