Publications
69 results found
Kostopoulou O, Sirota M, Round T, et al., 2016, The role of physicians’ first impressions in the diagnosis of possible cancers without alarm symptoms, Medical Decision Making, Vol: 37, Pages: 9-16, ISSN: 1552-681X
Background. First impressions are thought to exert a disproportionate influence on subsequent judgments; however, their role in medical diagnosis has not been systematically studied. We aimed to elicit and measure the association between first impressions and subsequent diagnoses in common presentations with subtle indications of cancer. Methods. Ninety UK family physicians conducted interactive simulated consultations online, while on the phone with a researcher. They saw 6 patient cases, 3 of which could be cancers. Each cancer case included 2 consultations, whereby each patient consulted again with nonimproving and some new symptoms. After reading an introduction (patient description and presenting problem), physicians could request more information, which the researcher displayed online. In 2 of the possible cancers, physicians thought aloud. Two raters coded independently the physicians’ first utterances (after reading the introduction but before requesting more information) as either acknowledging the possibility of cancer or not. We measured the association of these first impressions with the final diagnoses and management decisions. Results. The raters coded 297 verbalizations with high interrater agreement (Kappa = 0.89). When the possibility of cancer was initially verbalized, the odds of subsequently diagnosing it were on average 5 times higher (odds ratio 4.90 [95% CI 2.72 to 8.84], P < 0.001), while the odds of appropriate referral doubled (OR 1.98 [1.10 to 3.57], P = 0.002). The number of cancer-related questions physicians asked mediated the relationship between first impressions and subsequent diagnosis, explaining 29% of the total effect. Conclusion. We measured a strong association between family physicians’ first diagnostic impressions and subsequent diagnoses and decisions. We suggest that interventions to influence and support the diagnostic process should target its early stage of hypothesis generation.
Porat T, Kostopoulou O, Woolley A, et al., 2015, Eliciting user decision requirements for designing computerized diagnostic support for family physicians, Journal of Cognitive Engineering and Decision Making, Vol: 10, Pages: 57-73, ISSN: 1555-3434
Despite its 40-year history, computerized diagnostic support is not used in routine clinical practice. As part of a European project to develop computerized diagnostic support for family physicians, we identified user decision requirements and made design recommendations. To this end, we employed multiple data types and sources. All data were elicited from U.K. family physicians and pertained to consultations with patients, either real or simulated. To elicit user requirements, we conducted in situ observations and interviews with eight physicians and performed a hierarchical task analysis of the diagnostic task. We also analyzed 34 think-aloud transcripts of 17 family physicians diagnosing detailed patient scenarios on a computer and 24 interview transcripts of 18 family physicians describing past cases of intuitive diagnoses from their experience. All transcripts were coded using the situation assessment record (SAR) method. We report our methods and results using the decision-centered design framework. Studies employing multiple human factors techniques and data types in order to elicit user requirements are rare. Our approach enabled us to propose interface design recommendations that go beyond existing “differential diagnosis generators,” with the aim to improve physicians’ performance and acceptance of the resulting tool.
Nurek M, Kostopoulou O, Delaney BC, et al., 2015, Reducing diagnostic errors in primary care. A systematic meta-review of computerized diagnostic decision support systems by the LINNEAUS collaboration on patient safety in primary care, European Journal of General Practice, Vol: 21, Pages: 8-13, ISSN: 1751-1402
BACKGROUND: Computerized diagnostic decision support systems (CDDSS) have the potential to support the cognitive task of diagnosis, which is one of the areas where general practitioners have greatest difficulty and which accounts for a significant proportion of adverse events recorded in the primary care setting. OBJECTIVE: To determine the extent to which CDDSS may meet the requirements of supporting the cognitive task of diagnosis, and the currently perceived barriers that prevent the integration of CDDSS with electronic health record (EHR) systems. METHODS: We conducted a meta-review of existing systematic reviews published in English, searching MEDLINE, Embase, PsycINFO and Web of Knowledge for articles on the features and effectiveness of CDDSS for medical diagnosis published since 2004. Eligibility criteria included systematic reviews where individual clinicians were primary end users. Outcomes we were interested in were the effectiveness and identification of specific features of CDDSS on diagnostic performance. RESULTS: We identified 1970 studies and excluded 1938 because they did not fit our inclusion criteria. A total of 45 articles were identified and 12 were found suitable for meta-review. Extraction of high-level requirements identified that a more standardized computable approach is needed to knowledge representation, one that can be readily updated as new knowledge is gained. In addition, a deep integration with the EHR is needed in order to trigger at appropriate points in cognitive workflow. CONCLUSION: Developing a CDDSS that is able to utilize dynamic vocabulary tools to quickly capture and code relevant diagnostic findings, and coupling these with individualized diagnostic suggestions based on the best-available evidence has the potential to improve diagnostic accuracy, but requires evaluation.
Kostopoulou O, Lionis C, Angelaki A, et al., 2015, Early diagnostic suggestions improve accuracy of family physicians: a randomized controlled trial in Greece., Family Practice, Vol: 32, Pages: 323-328, ISSN: 1460-2229
BACKGROUND: In a recent randomized controlled trial, providing UK family physicians with 'early support' (possible diagnoses to consider before any information gathering) was associated with diagnosing hypothetical patients on computer more accurately than control. Another group of physicians, who gathered information, gave a diagnosis, and subsequently received a list of possible diagnoses to consider ('late support'), were no more accurate than control, despite being able to change their initial diagnoses. OBJECTIVE: To replicate the UK study findings in another country with a different primary health care system. METHODS: All study materials were translated into Greek. Greek family physicians were randomly allocated to one of three groups: control, early support and late support. Participants saw nine scenarios in random order. After reading some information about the patient and the reason for encounter, they requested more information to diagnose. The main outcome measure was diagnostic accuracy. RESULTS: One hundred fifty Greek family physicians participated. The early support group was more accurate than control [odds ratio (OR): 1.67 (1.21-2.31)]. Like their UK counterparts, physicians in the late support group rarely changed their initial diagnoses after receiving support. The pooled OR for the early support versus control comparison from the meta-analysis of the UK and Greek data was 1.40 (1.13-1.67). CONCLUSION: Using the same methodology with a different sample of family physicians in a different country, we found that suggesting diagnoses to consider before physicians start gathering information was associated with more accurate diagnoses. This constitutes further supportive evidence of a generalizable effect of early support.
Delaney BC, Curcin V, Andreasson A, et al., 2015, Translational Medicine and Patient Safety in Europe: TRANSFoRm-Architecture for the Learning Health System in Europe., Biomed Research International, Vol: 2015, ISSN: 2314-6133
The Learning Health System (LHS) describes linking routine healthcare systems directly with both research translation and knowledge translation as an extension of the evidence-based medicine paradigm, taking advantage of the ubiquitous use of electronic health record (EHR) systems. TRANSFoRm is an EU FP7 project that seeks to develop an infrastructure for the LHS in European primary care. Methods. The project is based on three clinical use cases, a genotype-phenotype study in diabetes, a randomised controlled trial with gastroesophageal reflux disease, and a diagnostic decision support system for chest pain, abdominal pain, and shortness of breath. Results. Four models were developed (clinical research, clinical data, provenance, and diagnosis) that form the basis of the projects approach to interoperability. These models are maintained as ontologies with binding of terms to define precise data elements. CDISC ODM and SDM standards are extended using an archetype approach to enable a two-level model of individual data elements, representing both research content and clinical content. Separate configurations of the TRANSFoRm tools serve each use case. Conclusions. The project has been successful in using ontologies and archetypes to develop a highly flexible solution to the problem of heterogeneity of data sources presented by the LHS.
Vadillo MA, Kostopoulou O, Shanks DR, 2015, A critical review and meta-analysis of the unconscious thought effect in medical decision making, FRONTIERS IN PSYCHOLOGY, Vol: 6, ISSN: 1664-1078
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- Citations: 13
Woolley A, Kostopoulou O, Delaney BC, 2015, Can medical diagnosis benefit from "unconscious thought"?, Medical Decision Making, Vol: 36, Pages: 541-549, ISSN: 1552-681X
The unconscious thought theory argues that making complex decisions after a period of distraction can lead to better decision quality than deciding either immediately or after conscious deliberation. Two studies have tested this unconscious thought effect (UTE) in clinical diagnosis with conflicting results. The studies used different methodologies and had methodological weaknesses. We attempted to replicate the UTE in medical diagnosis by providing favorable conditions for the effect while maintaining ecological validity. Family physicians (N= 116) diagnosed 3 complex cases in 1 of 3 thinking modes: immediate, unconscious (UT), and conscious (CT). Cases were divided into short sentences, which were presented briefly and sequentially on computer. After each case presentation, the immediate response group gave a diagnosis, the UT group performed a 2-back distraction task for 3 min before giving a diagnosis, and the CT group could take as long as necessary before giving a diagnosis. We found no differences in diagnostic accuracy between groups (P= 0.95). The CT group took a median of 7 s to diagnose, which suggests that physicians were able to diagnose "online," as information was being presented. The lack of a difference between the immediate and UT groups suggests that the distraction had no additional effect on performance. To assess the decisiveness of the evidence of this null result, we computed a Bayes factor (BF01) for the 2 comparisons of interest. We found a BF01of 5.76 for the UT versus immediate comparison and of 3.61 for the UT versus CT comparison. Both BFs provide substantial evidence in favor of the null hypothesis: physicians' diagnoses made after distraction are no better than diagnoses made either immediately or after self-paced deliberation.
Kostopoulou O, Rosen A, Round T, et al., 2015, Early diagnostic suggestions improve accuracy of GPs: a randomised controlled trial using computer-simulated patients, BRITISH JOURNAL OF GENERAL PRACTICE, Vol: 65, Pages: E49-E54, ISSN: 0960-1643
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- Citations: 49
Nurek M, Kostopoulou O, Hagmayer Y, 2014, Predecisional information distortion in physicians’ diagnostic judgments: Strengthening a leading hypothesis or weakening its competitor?, Judgment and Decision Making, Vol: 9, Pages: 572-585, ISSN: 1930-2975
Decision makers have been found to bias their interpretation of incoming information to support an emerging judgment (predecisional information distortion). This is a robust finding in human judgment, and was recently also established and measured in physicians’ diagnostic judgments (Kostopoulou et al. 2012). The two studies reported here extend this work by addressing the constituent modes of distortion in physicians. Specifically, we studied whether and to what extent physicians distort information to strengthen their leading diagnosis and/or to weaken a competing diagnosis. We used the “stepwise evolution of preference” method with three clinical scenarios, and measured distortion on separate rating scales, one for each of the two competing diagnoses per scenario.In Study 1, distortion in an experimental group was measured against the responses of a separate control group. In Study 2, distortion in a new experimental group was measured against participants’ own, personal responses provided under control conditions, with the two response conditions separated by a month. The two studies produced consistent results. On average, we found considerable distortion of information to weaken the trailing diagnosis but little distortion to strengthen the leading diagnosis. We also found individual differences in the tendency to engage in either mode of distortion. Given that two recent studies found both modes of distortion in lay preference (Blanchard, Carlson & Meloy, 2014; DeKay, Miller, Schley & Erford, 2014), we suggest that predecisional information distortion is affected by participant and task characteristics. Our findings contribute to the growing research on the different modes of predecisional distortion and their stability to methodological variation.
Kostopoulou O, Sirota M, Round T, et al., 2014, The role of information gathering and physician experience in detecting early presentations of cancer in primary care, Publisher: WILEY-BLACKWELL, Pages: 29-29, ISSN: 0961-5423
Sirota M, Juanchich M, Kostopoulou O, et al., 2014, Decisive Evidence on a Smaller-Than-YouThink Phenomenon: Revisiting the "1-in-X'' Effect on Subjective Medical Probabilities, MEDICAL DECISION MAKING, Vol: 34, Pages: 419-429, ISSN: 0272-989X
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- Citations: 20
Corrigan D, Hederman L, Khan H, et al., 2013, An Ontology-Driven Approach to Clinical Evidence Modelling Implementing Clinical Prediction Rules, E-Health Technologies and Improving Patient Safety: Exploring Organizational Factors, Editors: Moumtzoglou, Kastania, Hershey, PA, Publisher: IGI Global, Pages: 257-284
Woolley A, Kostopoulou O, 2013, Clinical Intuition in Family Medicine: More Than First Impressions, ANNALS OF FAMILY MEDICINE, Vol: 11, Pages: 60-66, ISSN: 1544-1709
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- Citations: 55
Hagmayer Y, Kostopoulou O, 2013, A probabilistic constraint satisfaction model of information distortion in diagnostic reasoning., Austin, TX, Cooperative Minds: Social Interaction and Group Dynamics, Publisher: Cognitive Science Society
Information distortion is a cognitive bias in sequential diagnostic reasoning. It means that assumptions about the diagnostic validity of later evidence are distorted in favor of the leading hypothesis. Therefore the bias contributes to a primacy effect. Current parallel constraint satisfaction models account for order effects and coherence shifts, but do not explain information distortion. As an alternative a new, probabilistic constraint satisfaction model is proposed, which considers uncertainty about diagnostic validity by defining probability distributions over coherence relations. Simulations based on the new model show that by shifting distributions in favor of the leading hypothesis an increase in coherence can be achieved. Thus the model is able to explain information distortion by assuming a need for coherence. It also accounts for a number of other recent findings on clinical diagnostic reasoning. Alternative models and necessary future research are discussed.
Corrigan D, Hederman L, Khan H, et al., 2012, An Ontology-Driven Approach to Clinical Evidence Modelling Implementing Clinical Prediction Rules, E-Health Technologies and Improving Patient Safety: Exploring Organizational Factors, Editors: Moumtzoglou, Kastania, Hershey, PA, Publisher: IGI Global, Pages: 257-284
Kostopoulou O, Russo JE, Keenan G, et al., 2012, Information Distortion in Physicians' Diagnostic Judgments, MEDICAL DECISION MAKING, Vol: 32, Pages: 831-839, ISSN: 0272-989X
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- Citations: 51
Kostopoulou O, 2010, Diagnosis of difficult cases in primary care, JOURNAL OF HEALTH SERVICES RESEARCH & POLICY, Vol: 15, Pages: 71-74, ISSN: 1355-8196
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- Citations: 3
Kostopoulou O, Mousoulis C, Delaney BC, 2009, Information search and information distortion in the diagnosis of an ambiguous presentation, Judgment and Decision Making, Vol: 4, Pages: 408-418, ISSN: 1930-2975
Physicians often encounter diagnostic problems with ambiguous and conflicting features. What are they likely to do in such situations? We presented a diagnostic scenario to 84 family physicians and traced their information gathering, diagnoses and management. The scenario contained an ambiguous feature, while the other features supported either a cardiac or a musculoskeletal diagnosis. Due to the risk of death, the cardiac diagnosis should be considered and managed appropriately. Forty-seven participants (56%) gave only a musculoskeletal diagnosis and 45 of them managed the patient inappropriately (sent him home with painkillers). They elicited less information and spent less time on the scenario than those who diagnosed a cardiac cause. No feedback was provided to participants. Stimulated recall with 52 of the physicians revealed differences in the way that the same information was interpreted as a function of the final diagnosis. The musculoskeletal group denigrated important cues, making them coherent with their representation of a pulled muscle, whilst the cardiac group saw them as evidence for a cardiac problem. Most physicians indicated that they were fairly or very certain about their diagnosis. The observed behaviours can be described as coherence- based reasoning, whereby an emerging judgment influences the evaluation of incoming information, so that confident judgments can be achieved even with ambiguous, uncertain and conflicting information. The role of coherence-based reasoning in medical diagnosis and diagnostic error needs to be systematically examined.
Kostopoulou O, Devereaux-Walsh C, Delaney BC, 2009, Missing Celiac Disease in Family Medicine: The Importance of Hypothesis Generation, MEDICAL DECISION MAKING, Vol: 29, Pages: 282-290, ISSN: 0272-989X
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- Citations: 28
Kostopoulou O, 2009, Diagnostic errors: psychological theories and research implications., Health Care Errors and Patient Safety, Editors: Hurwitz, Sheikh, Oxford, Publisher: Blackwell, ISBN: 9781444360318
Kostopoulou O, Delaney BC, Munro CW, 2008, Diagnostic difficulty and error in primary care - a systematic review, FAMILY PRACTICE, Vol: 25, Pages: 400-413, ISSN: 0263-2136
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- Citations: 108
Kostopoulou O, Oudhoff J, Nath R, et al., 2008, Predictors of diagnostic accuracy and safe management in difficult diagnostic problems in family medicine, MEDICAL DECISION MAKING, Vol: 28, Pages: 668-680, ISSN: 0272-989X
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- Citations: 42
Kostopoulou O, 2008, Do GPs report diagnostic errors?, FAMILY PRACTICE, Vol: 25, Pages: 1-2, ISSN: 0263-2136
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- Citations: 8
Kostopoulou O, Delaney B, 2007, Confidential reporting of patient safety events in primary care: results from a multilevel classification of cognitive and system factors, QUALITY & SAFETY IN HEALTH CARE, Vol: 16, Pages: 95-100, ISSN: 1475-3898
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- Citations: 34
Kostopoulou O, 2007, From cognition to the system: developing a multilevel taxonomy of patient safety in general practice, ERGONOMICS, Vol: 49, Pages: 486-502, ISSN: 0014-0139
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- Citations: 24
Harries C, Kostopoulou O, 2005, Measuring and Modelling Clinical Decision Making, Handbook of Health Research Methods: Investigation, Measurement and Analysis, Editors: Bowling, Ebrahim, Publisher: Open University Press, Pages: 331-361
Kostopoulou O, Wildman M, 2004, Sources of variability in uncertain medical decisions in the ICU: a process tracing study, QUALITY & SAFETY IN HEALTH CARE, Vol: 13, Pages: 272-280, ISSN: 1475-3898
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- Citations: 18
Greenhalgh T, Kostopoulou O, Harries C, 2004, Making decisions about benefits and harms of medicines, BMJ-BRITISH MEDICAL JOURNAL, Vol: 329, Pages: 47-50B, ISSN: 1756-1833
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- Citations: 22
Wildman MJ, O'Dea J, Kostopoulou O, et al., 2003, Variation in intubation decisions for patients with chronic obstructive pulmonary disease in one critical care network, QJM-AN INTERNATIONAL JOURNAL OF MEDICINE, Vol: 96, Pages: 583-591, ISSN: 1460-2725
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- Citations: 31
Wildman MJ, O'Dea J, Walia S, et al., 2002, Variation in consultant's prognostic estimates for identical patients may explain variation in COPD intensive care unit (ICU) admission: Simulation study from one critical care network, Winter Meeting of the British-Thoracic-Society, Publisher: BRITISH MED JOURNAL PUBL GROUP, ISSN: 0040-6376
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