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Abstract
Objectives Psychological biases can distort treatment decision-making. The availability heuristic is one such bias, wherein events that are recent, vivid or easily imagined are readily ‘available’ to memory and are therefore judged more likely to occur than expected based on epidemiological data. We assessed if the occurrence of a serious colonoscopy complication for a primary care physician’s patient influenced colonoscopy rates for the physician’s other patients.
Design Longitudinal study with time-varying exposure variables.
Setting/participants Individuals living in 51 hospital referral regions across the USA identified based on enrolment in fee-for-service Medicare during 2005–2010. We assigned patients to a primary care physician based on office visits during the prior 2 years.
Exposures For each physician in each month, we calculated the proportion of patients assigned to them who had a colonoscopy. We identified two serious complications of which the primary care provider would very likely be aware: gastrointestinal bleed or perforation leading to hospitalisation or death within 14 days of colonoscopy.
Main outcome measures We employed Poisson regression models including physician fixed effects to assess the change in number of colonoscopies in the four quarters following an adverse colonoscopy event.
Results We identified 5 360 191 patients assigned to 30 704 physicians. 4864 physicians (16%) had at least one patient with an adverse event. The estimated change in the quarterly number of colonoscopies among physicians’ patients was significantly lower in quarter 2 following an adverse colonoscopy event (change=−2.1% (95% CI −3.4 to −0.8%)), before returning to the rate expected in the absence of an adverse event.
Conclusions Having a patient experience a serious adverse colonoscopy event was associated with a small and temporary decline in colonoscopy rates among a physician’s other patients. This finding provides empirical evidence for the influence of notable adverse events on care, possibly due to the availability heuristic.
- colorectal cancer screening
- medical decision making
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Footnotes
Contributors NLK had full access to all of the data in the study and affirms that the manuscript is an honest, accurate and transparent account of the study being reported; that no important aspects of the study have been omitted and that any discrepancies from the study as planned (and, if relevant, registered) have been explained. Study concept and design, analysis and interpretation of data, critical revision of the manuscript for important intellectual content and final approval of the manuscript: all authors. Drafting of the manuscript: NLK.
Funding This work was supported by 1R01CA174468 from the National Cancer Institute. NLK is also supported by K24CA181510 from the National Cancer Institute.
Competing interests NLK previously served as a medical editor for the Informed Medical Decisions Foundation, now part of Healthwise, a non-profit organisation that seeks to improve healthcare decisions.
Ethics approval Harvard Medical School Committee on Human Studies.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement Data were obtained from the US Centers for Medicare and Medicaid Services (CMS). Due to data use agreement restrictions, we cannot share our project data with other investigators, but the Medicare data can be obtained from CMS. Statistical code is available from the authors upon request.