Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY.
Adult and Child Consortium of Health Outcomes Research and Delivery Science (ACCORDS); Division of Cardiology, University of Colorado School of Medicine, Aurora; Center of Innovation for Veteran-Centered and Value-Driven Care, VA Denver, Colo.
Am J Med. 2022 Jul;135(7):e182-e193. doi: 10.1016/j.amjmed.2022.02.036. Epub 2022 Mar 18.
Variation in clinicians' diagnostic test utilization is incompletely explained by demographics and likely relates to cognitive characteristics. We explored clinician factors associated with diagnostic test utilization.
We used a self-administered survey of attitudes, cognitive characteristics, and reported likelihood of test ordering in common scenarios; frequency of lipid and liver testing in patients on statin therapy. Participants were 552 primary care physicians, nurse practitioners, and physician assistants from practices in 8 US states across 3 regions, from June 1, 2018 to November 26, 2019. We measured Testing Likelihood Score: the mean of 4 responses to testing frequency and self-reported testing frequency in patients on statins.
Respondents were 52.4% residents, 36.6% attendings, and 11.0% nurse practitioners/physician assistants; most were white (53.6%) or Asian (25.5%). Median age was 32 years; 53.1% were female. Participants reported ordering tests for a median of 20% (stress tests) to 90% (mammograms) of patients; Testing Likelihood Scores varied widely (median 54%, interquartile range 43%-69%). Higher scores were associated with geography, training type, low numeracy, high malpractice fear, high medical maximizer score, high stress from uncertainty, high concern about bad outcomes, and low acknowledgment of medical uncertainty. More frequent testing of lipids and liver tests was associated with low numeracy, high medical maximizer score, high malpractice fear, and low acknowledgment of uncertainty.
Clinician variation in testing was common, with more aggressive testing consistently associated with low numeracy, being a medical maximizer, and low acknowledgment of uncertainty. Efforts to reduce undue variations in testing should consider clinician cognitive drivers.
临床医生诊断性检测的使用差异不能仅用人口统计学特征来解释，且可能与认知特征有关。我们探讨了与诊断性检测使用相关的临床医生因素。
我们使用了一份自我管理的调查问卷，内容包括态度、认知特征以及在常见情况下的检测订单报告可能性；他汀类药物治疗患者的血脂和肝功能检测频率。参与者为来自美国 8 个州 3 个地区的 552 名初级保健医生、护士从业者和医师助理，调查时间为 2018 年 6 月 1 日至 2019 年 11 月 26 日。我们测量了检测可能性评分：他汀类药物治疗患者检测频率和自我报告检测频率的 4 个回答的平均值。
受访者中 52.4%为住院医师，36.6%为主治医生，11.0%为护士从业者/医师助理；大多数为白人（53.6%）或亚洲人（25.5%）。中位数年龄为 32 岁；53.1%为女性。参与者报告为中位数 20%（应激试验）至 90%（乳房 X 线照相术）的患者开具了检测；检测可能性评分差异很大（中位数 54%，四分位距 43%-69%）。更高的分数与地理位置、培训类型、低算数能力、高医疗事故担忧、高医疗最大化得分、对不确定性的高压力、对不良后果的高关注以及对医疗不确定性的低承认有关。更频繁地检测血脂和肝功能与低算数能力、高医疗最大化得分、高医疗事故担忧以及对不确定性的低承认有关。
检测中的临床医生差异很常见，更具侵略性的检测始终与低算数能力、成为医疗最大化者以及对不确定性的低承认有关。减少不必要的检测差异的努力应考虑临床医生认知驱动因素。
