Mansoori Jason N, Clark Brendan J, Havranek Edward P, Douglas Ivor S
Division of Pulmonary and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver, CO, USA.
Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA.
MDM Policy Pract. 2022 May 14;7(1):23814683221099454. doi: 10.1177/23814683221099454. eCollection 2022 Jan-Jun.
Discordance with well-known sepsis resuscitation guidelines is often attributed to rational assessments of patients at the point of care. Conversely, we sought to explore the impact of choice architecture (i.e., the environment, manner, and behavioral psychology within which options are presented and decisions are made) on decisions to prescribe guideline-discordant fluid volumes.
We conducted an electronic, survey-based study using a septic shock clinical vignette. Physicians from multiple specialties and training levels at an academic tertiary-care hospital and academic safety-net hospital were randomized to distinct answer sets: control (6 fluid options), time constraint (6 fluid options with a 10-s limit to answer), or choice overload (25 fluid options). The primary outcome was discordance with Surviving Sepsis Campaign fluid resuscitation guidelines. We also measured response times and examined the relationship between each choice architecture intervention group, response time, and guideline discordance.
A total of 189 of 624 (30.3%) physicians completed the survey. Time spent answering the vignette was reduced in time constraint (9.5 s, interquartile range [IQR] 7.3 s to 10.0 s, < 0.001) and increased in choice overload (56.8 s, IQR 35.9 s to 86.7 s, < 0.001) groups compared with control (28.3 s, IQR 20.0 s to 44.6 s). In contrast, the relative risk of guideline discordance was higher in time constraint (2.07, 1.33 to 3.23, = 0.001) and lower in choice overload (0.75, 0.60, to 0.95, =0.02) groups. After controlling for time spent reading the vignette, the overall odds of choosing guideline-discordant fluid volumes were reduced for every additional second spent answering the vignette (OR 0.98, 0.97, to 0.99, < 0.001).
Choice architecture may affect fluid resuscitation decisions in sepsis regardless of patient conditions, warranting further investigation in real-world contexts. These effects should be considered when implementing practice guidelines.
Time constrained clinical decision making was associated with increased proportion of guideline-discordant responses and relative risk of failure to prescribe guideline-recommended intravenous fluids using a sepsis clinical vignette.Choice overload increased response times and was associated with decreased proportion of guideline-discordant responses and relative risk of guideline discordance.Physician odds of choosing to prescribe guideline-discordant fluid volumes were reduced with increased deliberation as measured by response times.Clinicians, researchers, policy makers, and administrators should consider the effect of choice architecture on clinical decision making and guideline discordance when implementing guidelines for sepsis and other acute care conditions.
与知名的脓毒症复苏指南不一致的情况通常归因于在医疗现场对患者的合理评估。相反，我们试图探讨选择架构（即呈现选项和做出决策的环境、方式及行为心理学）对开具不符合指南的液体量决策的影响。
我们使用脓毒性休克临床病例进行了一项基于调查的电子研究。来自一所学术型三级护理医院和一所学术型安全网医院的多个专业及不同培训水平的医生被随机分配到不同的答案集：对照组（6种液体选项）、时间限制组（6种液体选项，回答限时10秒）或选择过载组（25种液体选项）。主要结局是与《拯救脓毒症运动》液体复苏指南不一致。我们还测量了回答时间，并研究了每个选择架构干预组、回答时间和指南不一致之间的关系。
624名医生中有189名（30.3%）完成了调查。与对照组（28.3秒，四分位间距[IQR]20.0秒至44.6秒）相比，时间限制组回答病例所花费的时间减少（9.5秒，IQR 7.3秒至10.0秒，P<0.001），而选择过载组增加（56.8秒，IQR 35.9秒至86.7秒，P<0.001）。相比之下，时间限制组指南不一致的相对风险更高（2.07，1.33至3.23，P = 0.001），而选择过载组更低（0.75，0.60至0.95，P = 0.02）。在控制阅读病例所花费的时间后，回答病例每多花一秒，选择不符合指南的液体量的总体几率就会降低（比值比0.98，0.97至0.99，P<0.001）。
无论患者情况如何，选择架构可能会影响脓毒症中的液体复苏决策，值得在实际环境中进一步研究。在实施实践指南时应考虑这些影响。
使用脓毒症临床病例时，时间受限的临床决策与不符合指南的回答比例增加以及未开具指南推荐的静脉输液的相对风险增加相关。选择过载增加了回答时间，并与不符合指南的回答比例降低和指南不一致的相对风险降低相关。根据回答时间衡量，随着思考时间增加，医生选择开具不符合指南的液体量的几率降低。临床医生、研究人员、政策制定者和管理人员在实施脓毒症及其他急性病护理指南时应考虑选择架构对临床决策和指南不一致的影响。
