Abstract 15522: Physician-Level Barriers to the Incorporation of Individualized Risk Estimates in Medical Decision Making: Man Versus Machine

Abstract

Background: Bleeding and restenosis after percutaneous coronary intervention are both predictable and modifiable. However, evidence suggests that patients’ risk of bleeding or restenosis has little impact on clinical decision making. PRISM is a tool that generates and deploys individualized, validated risk estimates at the point of care. The present study sought to understand barriers to the use of risk estimates in interventional cardiologists’ (ICs) treatment decisions for patients undergoing percutaneous coronary intervention (PCI) from 8 U.S. hospitals where PRISM was recently implemented.

Methods: A multidisciplinary team conducted a qualitative descriptive study between July 2011 and Feb 2012. ICs were invited (n=57) and 27 interviewed either in-person (n=5) or via telephone (n=22). Three were IC fellows; 2 were female. The average years of interventional experience was 13 (0.5 - 30) years. All interviews were recorded (mean 26 min), transcribed verbatim and then were coded using descriptive content analyses until thematic saturation occurred.

Results: The majority of ICs were not apt to rely on PRISM as a physician decision making tool. For those who didn’t, a main theme was “man versus machine,” in that the IC relied on personal experience rather than the risk estimates generated by PRISM. Three subthemes also emerged: 1. Attribution to ego, “Some physicians think that they’ve been doing this for years and years and years and they don’t need someone else’s tool to help them explain to the patient what they think is important.” (IC#42-20; 24 years experience) 2. Judgments about competence, “These numbers are more clung to by the insecure or the inexperienced looking for justification of doing x rather than y.” (IC#44-23; 30 years experience) 3. Unrecognized value, “The typical phrase you hear from operators is that I already know that information. That information is already in my head.” (IC#04-06; 2 years experience)

Conclusion: ICs rely on subjective assessments, and their treatment decisions hinge on recall and experience, rather than objective risk estimates. Overcoming these barriers is necessary to integrate individualized risk estimates into medical decision making to provide safer, more evidence-based and more cost-effective care.