JAMDA
Volume 11, Issue 3 , Pages 194-203 , March 2010

Cognitive Bias and Planning Error: Nullification of Evidence-Based Medicine in the Nursing Home

  • Richard W. Miles, MD

      Affiliations

    • Corresponding Author InformationAddress correspondence to Richard W. Miles, MD, PO Box 3270, Bella Vista, AR 72715.

References 

  1. In:  Kohn L,  Corrigan J,  Donaldson M editor. To Err Is Human: Building a Safer Heath System. Washington, DC: National Academies Press; 1999;
  2. Berner E, Graber M. Overconfidence as a cause of diagnostic error in medicine. Am J Med. 2008;121:S2–S23
  3. Krosskerry P, Norman G. Overconfidence in clinical decision making. Am J Med. 2008;121:S24–S29
  4. Lindberg D. Introduction: Diagnostic error: is overconfidence the problem?. Am J Med. 2008;121;viii
  5. Norman G. Research in clinical reasoning: past history and current trends. Med Educ. 2005;39:418–427
  6. Leape L. Error in medicine. JAMA. 1994;272:1851–1857
  7. Reason J. Human Error. Cambridge, MA: Cambridge University Press; 1992;
  8. Miles R. The problem-integrated charting system: A symbol-enhanced method of longitudinal record keeping for complex patients. J Clin Outcomes Manag. 2006;5:279–287
  9. Wolff J, Starfield B, Anderson G. Prevalence, expenditures and complications of multiple chronic conditions in the elderly. Arch Intern Med. 2002;162:2269–2276
  10. Bodenheimer T, Fernandez A. High and rising health care costs. Part 4: Can costs be controlled while preserving quality?. Ann Intern Med. 2005;143:26–31
  11. Grabowski D, O'Malley J, Barhydt N. The costs and potential savings associated with nursing home hospitalizations. Health Aff. 2007;26:1753–1761
  12. Hickman S, Sabatino C, Moss A, Nester J. The POLST (physician orders for life-sustaining treatment) paradigm to improve end of life care: Potential state legal barriers to implementation. J Law Med Ethics. 2008;36:119–140
  13. Bodenheimer T. Coordinating care: A perilous journey through the health care system. N Engl J Med. 2008;358:1064–1071
  14. Gladwell M. Outliers: The Story of Success. New York: Little Brown and Company; 2008;
  15. Evert J, Sawler E, Bogan H, Perls T. Morbidity profiles of centenarians: Survivors, delayers, and escapers. J Gerontol. 2003;38:232–237
  16. Miles R. Treatment of hyperlipidemia in the nursing home. [letter] J Am Med Dir Assoc. 2008;9:204
  17. Levenson S, Morely JE. Evidence rocks in long-term care, but does it roll?. J Am Med Dir Assoc. 2007;8:493–501
  18. Morley JE. Caring for the vulnerable elderly: Are available quality indicators appropriate?. J Am Med Dir Assoc. 2007;8:1–2
  19. Messenger-Rapport B. Evidence-based medicine: Is it relevant to longterm care?. J Am Med Dir Assoc. 2004;5:328–332
  20. Morley JE. Evidence based medicine in the elderly. [Ed] Aging Successfully. 2007;XVII:2
  21. Levy C, Tiffany A, Williams A, Hutt E. Acute myocardial infarction in nursing home residents: Adherence to treatment guidelines reduces mortality, but why is adherence so low?. J Am Med Dir Assoc. 2008;10:56–61
  22. Kamel H. Update in osteoporosis management: Focus on bisphosphonates. J Am Med Dir Assoc. 2007;8:434–440
  23. Gupta G, Aronow W. Underuse of procedures for diagnosing osteoporosis and of therapies for osteoporosis in older nursing home residents. J Am Med Dir Assoc. 2003;4:200–202
  24. Kamel H. Underutilization of calcium and vitamin D supplements in an academic long-term care facility. J Am Med Dir Assoc. 2004;5:98–100
  25. Chandler J, Zimmerman S, Girman C, et al. Low bone mineral density and fracture risk in white female nursing home residents. JAMA. 2000;284:972–977
  26. Colon-Emeric C, Casebeer L, Saag K, et al. Barriers to providing osteoporosis care in skilled nursing facilities: Perceptions of medical directors and directors of nursing. J Am Med Dir Assoc. 2004;5:361–366
  27. Phillips L, Branch W, Cook C, et al. Clinical inertia. Ann Intern Med. 2001;135:825–834
  28. Kerr E, Zikmund-Fisher B, Klamerus M, et al. The role of clinical uncertainty in treatment decisions for diabetic patients with uncontrolled blood pressure. Ann Intern Med. 2008;148:717–727
  29. Wetle T. Age as a risk factor for inadequate treatment. JAMA. 1987;258:516
  30. Fox C, Tversky A. Ambiguity aversion and comparative ignorance. Q J Econ. 1995;110:585–603
  31. Miles R. Fallacious reasoning and complexity as root causes of clinical inertia. J Am Med Dir Assoc. 2007;8:349–354
  32. Schon D. Educating the Reflective Practitioner. San Francisco: Jossey-Bass; 1987;
  33. Pronovost P. Measuring preventable harm: Helping science keep pace with technology. JAMA. 2009;301:1273–1275
  34. Bar-Hillel M. On the subjective probability of compound events. Organ Behav Hum Perf. 1973;9:396–406
  35. Goldratt E. Theory of Constraints. Great Barrington, MA: The North River Press Publishing Corporation; 1990;
  36. Lindman H, Edwards W. Unlearning the gambler's fallacy. J Exp Psychol. 1961;62:63
  37. Ubel P. ‘What should I do doc?’ Some psychological benefits of physician recommendations. Arch Intern Med. 2002;162:977–980
  38. Fong G, Krantz D. The effects of statistical training on thinking about everyday problems. Cogn Psychol. 1986;18:253–292
  39. Pashter H. Dual task interference in simple tasks: Data and theory. Psychol Bull. 1994;116:220–244
  40. Spranca M, Minsk E, Baron J. Omission and commission in judgment and choice. J Exp Soc Psychol. 1991;27:76–105
  41. Redelmeier D, Tan S, Booth G. The treatment of unrelated disorders in patients with chronic medical diseases. N Engl J Med. 1998;338:1516–1520
  42. Eisenberg J, Williams S. Cost containment and changing physicians' practice behavior: Can the fox be taught to guard the chicken coop?. JAMA. 1981;246:2195–2201
  43. Miles R. Hip fracture reduction in Northwest Arkansas nursing homes. J Am Med Dir Assoc. 2008;9:449–453
  44. Darley J, Latané B. Bystander intervention in emergencies: Diffusion of responsibility. J Pers Soc Psychol. 1968;8:377–383
  45. Darley J, Batson O. From Jerusalem to Jericho: A study of situational and dispositional variables on helping behavior. J Pers Soc Psychol. 1973;7:100–108
  46. Stevenson L. Challenges for the basis of practice in heart failure. Circ Heart Fail. 2008;1:81–83
  47. Kahneman D, Tversky A. Prospect theory: An analysis of decision under risk. In:  Kahneman D,  Tversky A editor. Choices, Values and Frames. New York: Cambridge University Press; 2000;p. 17–43
  48. Reach G. A novel conceptual framework for understanding the mechanism of adherence to long term therapies. Patient Preferences and Adherence. 2008;2:7–19
  49. Reach G. Patient non-adherence and health care provider clinical inertia as clinical myopia. Diabetes Metab. 2008;34:382–385
  50. Loewenstein G, Prelec D. Preferences for sequences of outcomes. In:  Kahneman D,  Tversky A editor. Choices, Values and Frames. New York: Cambridge University Press; 2000;
  51. Loewenstein G, Prelec D. Anomalies in intertemporal choice: Evidence and interpretation. In:  Kahneman D,  Tversky A editor. Choices, Values and Frames. New York: Cambridge University Press; 2000;p. 578–596
  52. Bennett D. Randomness. Cambridge, MA: Harvard University Press; 1999;
  53. Fox C, Levav J. Partition-Edit-Count: Naïve extensional reasoning in judgment of conditional probability. J Exp Psychol Gen. 2004;133:626–664
  54. Taleb N. Fooled by Randomness: The Hidden Role of Chance in the Markets and in Life. New York: Texere; 2001;
  55. Mlodinow L. The Drunkard's Walk: How Randomness Rules Our Lives. New York: Pantheon Books; 2008;
  56. Kahneman D, Tversky A. Choices, values and frames. In:  Kahneman D,  Tversky A editor. Choices Values and Frames. New York: Cambridge University Press; 2000;p. 1–16
  57. Tversky A, Kahneman D. Advances in prospect theory: Cumulative representation of uncertainty. In:  Kahneman D,  Tversky A editor. Choices, Values and Frames. New York: Cambridge University Press; 2000;p. 44–65
  58. Miles R. Tailoring care for the elderly outlier. J Ark St Med Soc. 2009;105:256–257
  59. Clancy Brothers. Isn't it Grand Boys. In: Reunion [CD]. Shanachie Entertainment, 37 E. Clinton St., Newton, NJ, 1984.
  60. Lee S, Go A, Lindquist K, et al. Mortality among the oldest old. Am J Public Health. 2008;98:1209–1214
  61. van der Steen J, Mitchell S, Fritzers H, et al. Prediction of 6-month mortality in nursing home residents with advanced dementia: Validity of a risk score. J Am Med Dir Assoc. 2007;8:464–468
  62. Lee S, Lindquist K, Segal M, Covinski K. Development and validation of a prognostic index for 4-year mortality in older adults. JAMA. 2006;295:801–808
  63. Lunney J, Lynn J, Foley D, et al. Patterns of functional decline at the end of life. JAMA. 2003;289:2387–2392
  64. Hanson J. Shared decision making: Have we missed the obvious?. Arch Intern Med. 2008;168:1368–1370
  65. Fox C, Tversky A. A belief based account of decision under uncertainty. In:  Kahneman D,  Tversky A editor. Choices, Values and Frames. New York: Cambridge University Press; 2000;p. 118–142
  66. Zarowitz B, Stefanacci R, Hollenback K, O'Shea T. The application of evidence-based principles of care in older persons (Issue 1): Management of osteoporosis. J Am Med Dir Assoc. 2005;6:102–108
  67. Lyles K, Colon-Emerick C. Treating vitamin D deficiency in long-term care: It should be done yesterday, but how?. J Am Med Dir Assoc. 2004;6:416–417
  68. Jones E, Harris V. The attribution of attitudes. J Exp Soc Psychol. 1967;3:1–24
  69. Diamond G, Kaul S. The disconnect between practice guidelines and clinical practice—Stressed out. JAMA. 2008;300:1817–1818
  70. Kahneman D. Evaluation by moments: Past and future. In:  Kahneman D,  Tversky A editor. Choices, Values and Frames. New York: Cambridge University Press; 2000;p. 693–708
  71. Kahneman D. Experienced utility and objective happiness: A momentbased approach. In:  Kahneman D,  Tversky A editor. Choices, Values and Frames. New York: Cambridge University Press; 2000;p. 673–692
  72. Singer D, Albert G, Dalen J, et al. Antithrombotic therapy in atrial fibrillation: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2008;133:546S–592S
  73. Tversky A, Kahneman D. Context dependent preferences. In:  Kahneman D,  Tversky A editor. Choices, Values and Frames. New York: Cambridge University Press; 2000;p. 518–527
  74. Tversky A, Kahneman D. Rationale choice and the framing of decisions. In:  Kahneman D,  Tversky A editor. Choices, Values and Frames. New York: Cambridge University Press; 2000;p. 209–223
  75. Gage B, Albers G, Dalen J, et al. Validation of clinical classification schemes for predicting stroke: Results from the National Registry of Atrial Fibrillation. JAMA. 2001;285:2864–2870
  76. In:  Mayfield E editors. Antithrombotic therapy in the long-term care setting. Columbia, MD: American Medical Directors Association; 2006;
  77. Kahneman D, Ritov A, Schade D. Economic preferences or attitude expressions. In:  Kahneman D,  Tversky A editor. Choices, Values and Frames. New York: Cambridge University Press; 2000;p. 642–671
  78. Cross G, Vogel E, Dhond A, et al. Factors influencing physicians' reported use of anticoagulation therapy in non-valvular atrial fibrillation: A cross sectional survey. Clin Ther. 2003;25:1750–1764
  79. Shafir E, Diamond P, Tversky A. Money illusion. In:  Kahneman D,  Tversky A editor. Choices, Values and Frames. New York: Cambridge University Press; 2000;p. 335–355
  80. Cohn J. The fallacy of the mean. J Cardiac Failure. 2004;7:103–104
  81. Heart Protection Study Collaborative Group. MRC/BHF Heart protection study of cholesterol lowering with simvastatin in 20,536 high risk individuals: A randomized controlled trial. Lancet. 2002;360:7–22
  82. Koka M, Joseph J, Aranow W. Prevalence of adequate and of optimal control of serum low density lipoprotein cholesterol in an academic nursing home. J Am Med Dir Assoc. 2007;8:604–606
  83. Slovic P, Finucane M, Peters E, MacGregor D. The affect heuristic. In:  Gilovich T,  Griffin D,  Kahneman D editor. Heuristics and Biases. New York: Cambridge University Press; 2002;p. 397–420
  84. Trivers R. The elements of a scientific theory of self-deception. Ann N Y Acad Sci. 2000;907:114–131
  85. Perkins H. Controlling death: The false promise of advance directives. Ann Intern Med. 2007;147:51–57
  86. Johnson A, Brooksby P. Ten steps before you refer: Heart failure. Br J Cardiol. 2009;16:30–35
  87. Smith P, Araya-Guerra R, Bublitz C, et al. Missing clinical information during primary care visits. JAMA. 2005;293:565–571
  88. U.S. Preventive Services Task Force . Guide to Clinical Preventive Services. 2nd ed.. Baltimore: Williams & Wilkins; 1996;
  89. Schneider L. Comment on: Donepezil in Alzheimer's disease. Lancet. 2004;363:2105–2115
  90. Fehr E, Gächter S. Fairness and retaliation: The economics of reciprocity. Journal of Economic Perspective. 2000;14:159–181
  91. Tversky A, Kahneman D. Loss aversion in riskless choice. In:  Kahneman D,  Tversky A editor. Choices, Values, and Frames. New York: Cambridge University Press; 2000;p. 143–158
  92. Halvorsen P, Selmer R, Kristiansen I. Different ways to describe the benefits of risk-reducing treatments: A randomized trial. Ann Intern Med. 2007;146:848–856
  93. McNeil B, Pauker S, Sox H, Tversky A. On the elicitation of preferences for alternative therapies. N Engl J Med. 1982;306:1259–1262
  94. Thaler R. Mental accounting matters. In:  Kahneman D,  Tversky A editor. Choices Values and Frames. New York: Cambridge University Press; 2000;p. 241–268
  95. Hayward R. Performance measurement in search of a path. N Engl J Med. 2007;356:951–953
  96. Dharmarajan T, Pankratov A, Morris E, et al. Anemia: Its impact on hospitalizations and length of hospital stay in nursing home and community older adults. J Am Med Dir Assoc. 2008;9:354–359
  97. Charette S. Hospitalization of the nursing home patient. J Am Med Dir Assoc. 2003;4:90–94
  98. Holman H. Chronic disease—the need for a new clinical education. JAMA. 2004;292:1057–1059
  99. Gladwell M. The Tipping Point. New York: Little Brown and Company; 2000;
  100. Cassel C, Brennan T. Managing medical resources: Return to the commons?. JAMA. 2007;297:2518–2520

 The author has received no financial assistance and has no conflicts of interest regarding this article.

PII: S1525-8610(09)00290-4

doi: 10.1016/j.jamda.2009.08.007

JAMDA
Volume 11, Issue 3 , Pages 194-203 , March 2010

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