Clinicians' implicit and explicit attitudes about the legitimacy of functional neurological disorders correlate with referral decisions

Objectives

Uncertainty regarding the legitimacy of functional neurological disorder (FND) remains among some health care professionals. Despite treatment guidelines and consensus recommendations, variability in clinical practice referral decisions persists. Evidence from other conditions suggests such clinical decision making is impacted by practitioners' implicit and explicit attitudes. We aimed to identify whether health care professionals hold implicit and/or explicit attitudes about the legitimacy of FND and whether these attitudes are associated with referral decision making.

Design/Methods

We included 66 health care professionals who work with people with neurological conditions: n = 37 medical doctors, mainly neurologists (n = 18) and psychiatrists (n = 10), and n = 29 doctoral level practitioner psychologists. Participants completed an Implicit Association Test (IAT), Implicit Relational Assessment Procedure (IRAP), a referral decision-making vignette task and self-report measures of explicit attitudes on FND-legitimacy, therapeutic optimism and clinician confidence. Multiple Sclerosis (MS) was used as a comparator condition.

Results

Participants self-reported strong explicit FND-legitimate and MS-legitimate attitudes but demonstrated an implicit FND-illegitimate/MS-legitimate bias. Deeper examination provided by the IRAP data indicated pro-FND-legitimate attitudes, but no bias for or against FND-illegitimate—contrasting the pro-MS-legitimate, anti-MS-illegitimate attitudes for the comparator condition. Attitudes about FND-illegitimacy were negatively associated with likelihood of referral to physical interventions such as physiotherapy. Medical doctors had lower treatment optimism and stronger explicit attitudes that FND is illegitimate than psychologists.

Conclusions

At an implicit level, clinicians are uncertain about the illegitimacy of FND, and such attitudes are associated with lower likelihood of referral to physiotherapy in particular. Improved education on FND among health care professionals is indicated.     

Frequency and outcomes of STEMI patients presenting between 12 and 24 h after symptom onset: Late-presenting STEMI

Background

In the last decade, percutaneous coronary intervention (PCI) has evolved toward the treatment of complex disease in patients with multiple comorbidities. Whilst there are several definitions of complexity, it is unclear whether there is agreement between cardiologists in classifying complexity of cases. Inconsistent identification of complex PCI can lead to significant variation in clinical decision-making.

Aim

This study aimed to determine the inter-rater agreement in rating the complexity and risk of PCI procedures.

Method

An online survey was designed and disseminated amongst interventional cardiologists by the European Association of Percutaneous Cardiovascular Intervention (EAPCI) board. The survey presented four patient vignettes, with study participants assessing these cases to classify their complexity.

Results

From 215 respondents, there was poor inter-rater agreement in classifying the complexity level (k = 0.1) and a fair agreement (k = 0.31) in classifying the risk level. The experience level of participants did not show any significant impact on the inter-rater agreement of rating the complexity level and the risk level. There was good level of agreement between participants in terms of rating 26 factors for classifying complex PCI. The top five factors were (1) impaired left ventricular function, (2) concomitant severe aortic stenosis, (3) last remaining vessel PCI, (4) requirement fort calcium modification and (5) significant renal impairment.

Conclusion

Agreement among cardiologists in classifying complexity of PCI is poor, which may lead to suboptimal clinical decision-making, procedural planning as well as long-term management. Consensus is needed to define complex PCI, and this requires clear criteria incorporating both lesion and patient characteristics.     

Patient and specimen identification in a tertiary care pediatric hospital: Barcodes do not scan themselves

Background

Despite the safety improvements linked to the use of barcodes for patient and specimen identification, patient misidentification remains a leading cause of transfusion-associated reactions including fatalities. A wealth of evidence supports the use of barcodes in general, but there is less published evidence of real-world barcode compliance. This project investigates barcode scanning compliance for patient and specimen identification at a tertiary care pediatric/maternity hospital.

Study Design and Methods

Transfusion laboratory specimen collection noncompliance events between January 1, 2019, and December 31, 2019 were retrieved from the hospital laboratory information system. Data were analyzed including stratification of collections by collector role and collection event. A survey of blood collectors was conducted.

Results

Collection compliance for 6285 blood typing specimens was evaluated. Full barcode scanning identification of both patient and specimen was utilized in only 33.6% of total collections. The remaining two thirds of collections were overridden by the blood collector: no barcode scanning occurred in 31.3%, while the specimen accession label was scanned but not the patient armband in 32.3% of total collections. There were significant differences between phlebotomists and nurses, with more phlebotomists performing the full scanning and specimen scanning only, while more nurses obtained specimens without patient or specimen scanning (p < .001). Blood collectors identified hardware challenges and training gaps as key contributors to barcode noncompliance.

Discussion

Our study highlights an instance of poor barcode scanning compliance for patient and specimen identification. We formulated improvement strategies and launched a quality improvement project to address factors influencing noncompliance.