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Referral decision making of General Practitioners: a signal detection study

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Title: Referral decision making of General Practitioners: a signal detection study
Authors: Kostopoulou, O
Nurek, M
Cantarella, S
Okoli, G
Fiorentino, F
Delaney, B
Item Type: Journal Article
Abstract: Background. Signal detection theory (SDT) describes how respondents categorize ambiguous stimuli over repeated trials. It measures separately “discrimination” (ability to recognize a signal amid noise) and “criterion” (inclination to respond “signal” v. “noise”). This is important because respondents may produce the same accuracy rate for different reasons. We employed SDT to measure the referral decision making of general practitioners (GPs) in cases of possible lung cancer. Methods. We constructed 44 vignettes of patients for whom lung cancer could be considered and estimated their 1-year risk. Under UK risk-based guidelines, half of the vignettes required urgent referral. We recruited 216 GPs from practices across England. Practices differed in the positive predictive value (PPV) of their urgent referrals (chance of referrals identifying cancer) and the sensitivity (chance of cancer patients being picked up via urgent referral from their practice). Participants saw the vignettes online and indicated whether they would refer each patient urgently or not. We calculated each GP’s discrimination (d ′) and criterion (c) and regressed these on practice PPV and sensitivity, as well as on GP experience and gender. Results. Criterion was associated with practice PPV: as PPV increased, GPs’c also increased, indicating lower inclination to refer (b = 0.06 [0.02–0.09]; P = 0.001). Female GPs were more inclined to refer than male GPs (b = −0.20 [−0.40 to −0.001]; P = 0.049). Average discrimination was modest (d′ = 0.77), highly variable (range, −0.28 to 1.91), and not associated with practice referral performance. Conclusions. High referral PPV at the organizational level indicates GPs’ inclination to avoid false positives, not better discrimination. Rather than bluntly mandating increases in practice PPV via more referrals, it is necessary to increase discrimination by improving the evidence base for cancer referral decisions.
Issue Date: 1-Jan-2019
Date of Acceptance: 19-Oct-2018
URI: http://hdl.handle.net/10044/1/65761
DOI: https://dx.doi.org/10.1177/0272989X18813357
ISSN: 0272-989X
Publisher: SAGE Publications
Start Page: 21
End Page: 31
Journal / Book Title: Medical Decision Making
Volume: 39
Issue: 1
Copyright Statement: © 2018 The Author(s). This article is distributed under the terms of the Creative Commons Attribution 4.0 License (http://www.creativecommons.org/licenses/by/4.0/) which permits any use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage).
Sponsor/Funder: Cancer Research UK
Funder's Grant Number: C33754/A17871
Keywords: Science & Technology
Life Sciences & Biomedicine
Health Care Sciences & Services
Medical Informatics
cancer referral
conversion rate
detection rate
primary care
signal detection theory
Psychology & Cognitive Sciences
Behavioral Science & Comparative Psychology
Decision Making
Signal Detection, Psychological
1117 Public Health And Health Services
1402 Applied Economics
Health Policy & Services
Publication Status: Published
Online Publication Date: 2018-12-27
Appears in Collections:Department of Surgery and Cancer