NEW YORK (Reuters Health) – After complications during their patient’s vaginal delivery, doctors are more likely to switch to cesarean delivery with the next patient, a new study suggests.
Likewise, after complications during a cesarean delivery, the next delivery they assist is more apt to be vaginal, Dr. Manasvini Singh of the University of Massachusetts, in Amherst, reports in Science.
“Physicians rely on heuristics – simplified decision rules – to make delivery decisions under uncertainty,” Dr. Singh told Reuters Health by email. “When a physician’s prior patient has complications in one delivery mode, the physician is more likely to switch to the other delivery mode on the next patient, regardless of patient indication. This has small but significantly negative effects on patient health and it increases the use of resources.”
Dr. Singh examined 21 years’ worth of inpatient electronic health record (EHR) data covering more than 86,000 deliveries by 231 physicians in the obstetric wards of two academic hospitals. The records provided time stamps as patients advanced through their hospital stay, allowing her to identify which physicians delivered which babies and to place the deliveries in sequential order.
She matched each doctor’s current patient delivery mode with both that doctor’s prior patient’s delivery mode, and with complications during the prior patient’s delivery. Complications included fetal distress, umbilical cord complications, obstructed labor, obstetric trauma, postpartum hemorrhage, and perineal laceration.
Doctors were 3.4% more likely to switch to vaginal delivery after complications during a cesarean (P=0.01) and 3.6% more likely to switch to cesarean after complications with vaginal delivery (P=0.045).
Compared with switching delivery modes after no complications, switching delivery modes after complications was linked with significantly worse health outcomes, including a 0.04 standard deviation (SD) increase in maternal and neonatal mortality, a 0.03 SD decrease in home discharge, and a 0.04 SD increase in number of 30-day outpatient visits.
Measures of service use increased slightly, including the numbers of Current Procedural Terminology (CPT) codes on record, diagnosis-related group (DRG) charges, medications administered to the newborn, and obstetricians on the encounter record.
“These results do not imply that the use of these heuristics is the physician’s fault, or that physicians are being negligent in any way,” Dr. Singh explained by email. “Relying on heuristics is a very human tendency.”
“Understanding the heuristics that physicians use to manage the complexity, uncertainty, and emotional toll of the clinical environments they operate in is important for designing interventions that can improve such decision-making and patient care,” she explained. “Making physicians aware of the heuristics they use can help them avoid their use. Unobtrusive artificial intelligence and/or decision support systems may also be used to improve physician decision-making, although their implementation is challenging.”
In an editorial about the study, Drs. Meng Li of the University of Colorado, in Denver, and Helen Colby of Indiana University, in Indianapolis, write, “It is time to acknowledge the prevalence of heuristics and decision biases in clinical practice and to view these patterns as predictably human instead of blaming individual doctors. Only then can we start helping doctors improve clinical decisions and, as a result, the health of the public.”
Dr. Aaron B. Caughey, chair of obstetrics and gynecology and associate dean for women’s health research and policy at Oregon Health and Science University, in Portland, told Reuters Health by email, “Gaining awareness of these biases and insight into how providers make clinical decisions is important. With awareness, we can work to correct the biases. With fewer biases, we can provide more evidence-based care.”
“This kind of behavior is common,” he said by email. “Recent experiences inform how we manage current patients, whether in mode of delivery or diagnosis.”
Dr. Caughey, who was not involved in the study, noted that the data quality and analytic approach are strengths of the study. A weakness he found is “that we don’t really know why the clinicians were choosing to do the cesareans, so a study exploring that may help us better understand what clinicians are doing and why.”
SOURCES: https://bit.ly/3CnN6mr and https://bit.ly/3bc0Ch2 Science, online October 15, 2021.
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