Do first opinions affect second opinions?

BACKGROUND: Second medical opinions have become commonplace and even mandatory in some health-care systems, as variations in diagnosis, treatment or prognosis may emerge among physicians. OBJECTIVE: To evaluate whether physicians' judgment is affected by another medical opinion given to a patient. DESIGN: Orthopedic surgeons and neurologists filled out questionnaires presenting eight hypothetical clinical scenarios with suggested treatments. One group of physicians (in each specialty) was told what the other physician's opinion was (study group), and the other group was not told what it was (control group). PARTICIPANTS: A convenience sample of 332 physicians in Israel: 172 orthopedic surgeons (45.9% of their population) and 160 neurologists (64.0% of their population). MEASUREMENTS: Scoring was by choice of less or more interventional treatment in the scenarios. We used χ(2) tests and repeated measures ANOVA to compare these scores between the two groups. We also fitted a cumulative ordinal regression to account for the dependence within each physician's responses. RESULTS: Orthopedic surgeons in the study group chose a more interventionist treatment when the other physician suggested an intervention than those in the control group [F (1, 170) =4.6, p=0.03; OR=1.437, 95% CI 1.115-1.852]. Evaluating this effect separately in each scenario showed that in four out of the eight scenarios, they chose a more interventional treatment when the other physician suggested an intervention (scenario 1, p=0.039; scenario 2, p<0.001; scenario 3, p=0.033; scenario 6, p<0.001). These effects were insignificant among the neurologists [F (1,158) =0.44, p=0.51; OR=1.087, 95% CI 0.811-1.458]. In both specialties there were no differences in responses by level of clinical experience [orthopedic surgeons: F (2, 166) =0.752, p=0.473; neurologists: F (2,154) =1.951, p=0.146]. CONCLUSIONS: The exploratory survey showed that in some cases physicians' judgments may be affected by other physicians' opinions, but unaffected in other cases. Weighing previous opinions may yield a more informed clinical decision, yet physicians may be unintentionally influenced by previous opinions. Second opinion has the potential to improve the clinical decision-making processes, and mechanisms are needed to reconcile discrepant opinions.

[Second medical opinions].

Second opinion is a decision-support tool for ratification or modification of a suggested treatment, by another physician. Second opinion may have a critical influence on the diagnosis, treatment and prognosis. The patient can benefit from treatment optimization and avoid unnecessary risks. The physician can benefit from less exposure to legal claims, and healthcare organizations can benefit from increased treatment, quality assurance and costs saving from unnecessary surgery and treatments. Nevertheless, injudicious use of this tool can provoke unnecessary medical costs. In recent years, many patients prefer to seek a second opinion on their disease and available treatments. Private and public insurance companies are trying to control surgery costs by urging and even demanding a second opinion before surgery. Although second opinions are common in medical practice, relatively little is known on this subject. Most of the studies reviewed in this article evaluated the clinical benefit of second opinions, the reasons patients seek a second opinion and the characteristics of these patients, as well as technological interventions to promote second opinions, and ethical or legal issues related to second opinions. Yet, there are opportunities for further studies about physicians attitudes and barriers towards second opinions, their effect on patient-physician communication and cost-effectiveness analyses of second opinions. Due to the relevance of second opinions for public heath, this review aims to summarize the current research on second opinions.

Physician adherence to the dyslipidemia guidelines is as challenging an issue as patient adherence.

BACKGROUND: A wide therapeutic gap exists between evidence-based guidelines and their practice in the primary care, which is primarily attributed to physician and patient adherence. OBJECTIVE: This study aims to differentiate physician and patient adherence to dyslipidemia secondary prevention guidelines and various factors affecting it. METHODS: A post hoc analysis of data collected by a prospective cluster randomized trial with 7041 patients diagnosed with clinical atherosclerosis requiring secondary prevention of dyslipidemia and 127 primary care physicians over an 18-month period. Adherence was measured by physicians' and patients' actions taken according to the guidelines and correlated using multivariate logistic regressions. RESULTS: Physician adherence was 36.9% for lipid profile screening, 27.6% for pharmacotherapy up-titration and 21.0% for pharmacotherapy initiation. Physician adherence was positively correlated with frequent patient visits [odds ratios (OR = 1.304)], having more dyslipidemic patients (OR = 1.304) and treating immigrants (OR = 1.268). Patient adherence was 83.8%, 71.9% and 62.6% for medication up-titration, lipid profile screening and pharmacotherapy initiation, respectively. Patient adherence was affected by attending clinics with many dyslipidemic patients (OR = 1.542), being older (OR = 1.271) and being treated by a male physician (OR = 0.870). CONCLUSIONS: We learn from this study that (i) physician non-adherence was a major cause for the failure to follow guidelines, (ii) pharmacotherapy initiation was the most challenging issue to tackle and (iii) greater adherence occurred mainly in high volume conditions (patients and visits). Practical implications are designated focus on metabolic condition prevention in primary care by cardiologists or primary care clinics specializing in metabolic conditions and the need to facilitate more frequent follow-up visits.

Adherence by primary care physicians to guidelines for the clinical management of dyslipidemia.

BACKGROUND: There is a wide treatment gap between evidence-based guidelines and their implementation in primary care. OBJECTIVE: To evaluate the extent to which physicians "literally" follow guidelines for secondary prevention of dyslipidemia and the extent to which they practice "substitute" therapeutic measures. METHODS: We performed a post hoc analysis of data collected in a prospective cluster randomized trial. The participants were 130 primary care physicians treating 7745 patients requiring secondary prevention of dyslipidemia. The outcome measure was physician literal adherence or substitute adherence. We used logistic regressions to evaluate the effect of various clinical situations on literal and substitute adherence. RESULTS: Literal adherence was modest for ordering a lipoprotein profile (35.1%) and for pharmacotherapy initiations (26.0%), but rather poor for drug up-titrations (16.1%) and for referrals for specialist consultation (3.8%). In contrast, many physicians opted for substitute adherence for up-titrations (75.9%) and referrals for consultation (78.7%). Physicians tended to follow the guidelines literally in simple clinical situations (such as the need for lipid screening) but to use substitute measures in more complex cases (when dose up-titration or metabolic consultation was required). Most substitute actions were less intense than the actions recommended by the guidelines. CONCLUSIONS: Physicians often do not blindly follow guidelines, but rather evaluate their adequacy for a particular patient and adjust the treatment according to their assessment. We suggest that clinical management be evaluated in a broader sense than strict guideline adherence, which may underestimate physicians' efforts.

Factors affecting physicians compliance with enrollment suggestions into a clinical reminders intervention.

Clinical reminders can promote adherence with evidence-based clinical guidelines, but they may also have unintended consequences such as alert fatigue, false alarms and increased workload, which cause clinicians to ignore them. The described clinical reminder system identifies patients eligible for primary prevention of cardiovascular diseases and lets the physician to choose which patients will be included in the reminders intervention. We analyzed data of 87,165 visits of 35,699 patients and evaluated factors which may affect clinicians' decision to enroll patients to the intervention. The physicians included most of the patients suggested for inclusion (85.7%). Yet, they skipped the enrollment suggestion in 62.6% of the visits. Patients with a cardiovascular disease, dyslipidemia, diabetes, or hypertension were more likely to be included in the intervention, while older patients were less likely to be included. Insights regarding the usability of clinical reminders are discussed.

Defining and measuring physicians' responses to clinical reminders.

Decision-support systems, and specifically rule-based clinical reminders, are becoming common in medical practice. Despite their potential to improve clinical outcomes, physicians do not always use information from these systems. Concepts from the cognitive engineering literature on users' responses to warning systems may help to define physicians' responses to reminders. Based on this literature, we suggest an exhaustive set of possible responses to clinical reminders, consisting of four responses named "Compliance", "Reliance", "Spillover" and "Reactance". We suggest statistical measures to estimate these responses and empirically demonstrate them on data from a large-scale clinical reminder system for secondary prevention of cardiovascular diseases. There was evidence for Compliance, probably since the physicians found the reminders informative, but not for Reliance, in line with the notion that Compliance and Reliance are two distinct types of trust in information from decision-support systems. Our research supports the notion that CDSS can promote closing the treatment gap and improve physicians' adherence to guidelines.

General practitioners' adherence with clinical reminders for secondary prevention of dyslipidemia.

A variety of computer-based applications, including computerized clinical reminders, are intended to increase adherence to evidence-based clinical guidelines. The value of these systems in clinical practice is still unclear. One reason for the limited success of clinical reminders may be physicians' low tendency to adhere to their advice. We studied the determinants of physicians' adherence to clinical advice regarding the management of dyslipidemia. Overall, the clinical reminders increased physicians' adherence to the clinical guidelines. Physicians were more compliant with the reminders when they experienced a greater patients' load, when they were less acquainted with the patient, and when more time has passed since the last major cardiac event. These findings can help to predict physicians' adherence and to improve the usage of clinical reminders for the benefit of patients, physicians and HMOs.