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Understanding the Role of the Ottawa Ankle Rules in Physicians’ Radiography

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Understanding the Role of the Ottawa Ankle Rules in Physicians’ Radiography Understanding the Role of the Ottawa Ankle Rules in Physicians’ Radiography Decisions: A Social Judgment Analysis Approach Ania Syrowatka Thesis submitted to the Faculty of Graduate and Postdoctoral Studies in partial fulfillment of the requirements for the M.Sc. Degree in Epidemiology Department of Epidemiology and Community Medicine Faculty of Medicine University of Ottawa © Ania Syrowatka, Ottawa, Canada, 2012 ABSTRACT Clinical decision rules improve health care fidelity, benefit patients, physicians and healthcare systems, without reducing patient safety or satisfaction, while promoting cost-effective practice standards. It is critical to appropriately and consistently apply clinical decision rules to realize these benefits. The objective of this thesis was to understand how physicians use the Ottawa Ankle Rules to guide radiography decision- making. The study employed a clinical judgment survey targeting members of the Canadian Association of Emergency Physicians. Statistical analyses were informed by the Brunswik Lens Model and Social Judgment Analysis. Physicians’ overall agreement with the ankle rule was high, but can be improved. Physicians placed greatest value on rule-based cues, while considering non-rule-based cues as moderately important. There is room to improve physician agreement with the ankle rule and use of rule-based cues through knowledge translation interventions. Further development of this Lens Modeling technique could lend itself to a valuable cognitive behavioral intervention. ii ACKNOWLEDGMENTS I would like to express my sincere gratitude to my primary supervisor, Dr. Jamie Brehaut, for his mentorship, support and scientific guidance throughout this thesis project. I would like to thank my co-supervisor, Dr. Tim Ramsay, for sharing his statistical expertise to guide analyses of this thesis. I would like to thank Dr. Ian Stiell, Dr. Christian Vaillancourt, and Dr. Jeffrey Perry for their contributions to the development and implementation of the clinical judgment survey, and the larger project from which this thesis was drawn. I would like to thank the members of the Canadian Association of Emergency Physicians who completed the survey. I would like to thank Dr. Robert Wigton and Dr. Thomas Tape for providing Social Judgment Analysis expertise. I would like to thank all of my lab members from the Ottawa Hospital Research Institute and classmates from the Department of Epidemiology and Community Medicine for making this a very enjoyable experience. Lastly, I would like to thank my parents for their support, understanding and patience as I completed my Master’s degree. iii PREFACE Dr. Brehaut developed a series of written hypothetical patient vignettes to elicit clinical decisions from a sample of emergency department physicians; the survey was already completed prior to beginning this thesis. The thesis involved statistical analysis of survey data using Social Judgment Analysis to assess whether rule-based and/or non- rule-based cues informed physician radiography decision-making. The study targeted three hypotheses designed to understand the role of the Ottawa Ankle Rules in these hypothetical decisions. iv TABLE OF CONTENTS Abstract................................................................................................................................ ii Acknowledgements............................................................................................................ iii Preface................................................................................................................................ iv List of tables...................................................................................................................... vii List of figures................................................................................................................... viii Introduction The strengths and weaknesses of evidence-based medicine........................................... 1 Health care fidelity: Are patients receiving optimal care?........................................... ...4 The role of knowledge translation for improving health care fidelity............................ 6 Clinical decision rules: Example of an actionable knowledge translation product........ 9 Case study: Ottawa Ankle Rules................................................................................... 11 Motivation for further research..................................................................................... 15 Social Judgment Analysis approach to evaluate medical decision-making.................. 16 Survey vignettes: A common method for conducting Social Judgment Analysis........ 23 Summary....................................................................................................................... 24 Research questions............................................................................................................. 25 Methods Work previously completed; Survey design and administration Study participants................................................................................................... 27 Study administration.............................................................................................. 27 Survey design......................................................................................................... 28 Reliability check.....................................................................................................31 Interpreting decisions via Brunswik’s Lens Model............................................... 32 Response rates and mail-out process......................................................................33 Work completed for thesis; Statistical analysis Exploratory and non-responder analyses............................................................... 36 Research Question 1: What is the rate of physician agreement with the ankle rule?.........................38 Research Question 2: A) Do cues based on the ankle rule have a greater impact on physician judgment than non-rule-based cues? B) With regard to non-rule-based cues, do related cues have a greater impact on physician judgment than unrelated cues?....................................... 41 Research Question 3: Do judgment policies differ among identifiable subgroups of physicians (i.e. self-reported consistency in using the rule, and different levels of expertise)? Value of self-reported use of the rule in radiography decision-making.... 44 Role of physician expertise in radiography decision-making.................... 44 v Results Exploratory and non-responder analyses...................................................................... 45 Early versus late responder analysis............................................................................. 48 Fit of the Lens Model.................................................................................................... 49 Three types of judgment policies.................................................................................. 51 Representativeness of the survey task........................................................................... 55 Research Question 1: What is the rate of physician agreement with the ankle rule?................................57 Research Question 2: A) Do cues based on the ankle rule have a greater impact on physician judgment than non-rule-based cues? B) With regard to non-rule-based cues, do related cues have a greater impact on physician judgment than unrelated cues?.......................................................... 61 Research Question 3: Do judgment policies differ among identifiable subgroups of physicians (i.e. self reported consistency in using the rule, and different levels of expertise)? Value of self-reported use of the rule in radiography decision-making..... 64 Role of physician expertise in radiography decision-making.................... 67 Discussion Basic agreement with the ankle rule............................................................................. 71 Fit of the Lens Model.................................................................................................... 74 Social Judgment Analysis............................................................................................. 74 Factors influencing physician agreement...................................................................... 77 Value of self-reported use of the rule in radiography decision-making........................ 78 Role of physician expertise in radiography decision-making....................................... 80 Generalizability of research findings............................................................................ 80 Limitations.................................................................................................................... 82 Significance and future directions................................................................................. 86 Conclusion………………………................................................................................. 91 References.......................................................................................................................... 92 Appendix A: Physician judgment survey.......................................................................... 97 vi LIST OF TABLES 1 Factors systematically varied in survey vignettes.............................................. 30 2 Demographic and professional information for responders and non-responders..................................................................................................
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