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Prospective Analysis of Decision Making During Joint Cardiology Cardiothoracic Conference in Treatment of 107 Consecutive Children with Congenital Heart Disease

Pediatric Cardiology volume 39, pages 1330–1338 (2018)Cite this article

Abstract

The complexity and potential biases involved in decision making have long been recognised and examined in both the aviation and business industries. More recently, the medical community have started to explore this concept and its particular importance in our field. Paediatric cardiology is a rapidly expanding field and for many of the conditions we treat, there is limited evidence available to support our decision-making. Variability exists within decision-making in paediatric cardiology and this may influence outcomes. There are no validated tools available to support and examine consistent decision-making for various treatment strategies in children with congenital heart disease in a multidisciplinary cardiology and cardiothoracic institution. Our primary objective was to analyse the complexity of decision-making for children with cardiac conditions in the context of our joint cardiology and cardiothoracic conference (JCC). Two paediatric cardiologists acted as investigators by observing the weekly joint cardiology–cardiothoracic surgery conference and prospectively evaluating the degree of complexity of decision-making in the management of 107 sequential children with congenital heart disease discussed. Additionally, the group consensus on the same patients was prospectively assessed to compare this to the independent observers. Of 107 consecutive children discussed at our JCC conference 32 (27%) went on to receive surgical intervention, 20 (17%) underwent catheterisation and 65 (56%) received medical treatment. There were 53 (50%) cases rated as simple by one senior observer, while 54 (50%) were rated as complex to some degree. There was high inter-observer agreement with a Krippendorff’s alpha of ≥ 0.8 between 2 observers and between 2 observers and the group consensus as a whole for grading of the complexity of decision-making. Different decisions were occasionally made on patients with the same data set. Discussions revisiting the same patient, in complex cases, resulted in different management decisions being reached in this series. Anchoring of decision-making was witnessed in certain cases. Potential application of decision making algorithms is discussed in making decisions in paediatric cardiology patients. Decision-making in our institution’s joint cardiology–cardiothoracic conference proved to be complex in approximately half of our patients. Inconsistency in decision-making for patients with the same diagnosis, and different decisions made for the same complex patient at different time points confounds the reliability of the decision-making process. These novel data highlight the absence of evidence-based medicine for many decisions, occasional lack of consistency and the impact of anchoring, heuristics and other biases in complex cases. Validated decision-making algorithms may assist in providing consistency to decision-making in this setting.

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Acknowledgements

We wish to acknowledge Professor Nathan Novemsky, Professor of Marketing and Psychology, Yale School of Behavioural Management, New Haven, Connecticut, U.S.A. for his original encouragement to study this area. We are also grateful to Mr. Andrew Pendred for generating the figures. We are grateful to our colleagues for allowing us study their decision-making process in the ‘JCC’.

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Affiliations

  1. Department of Paediatric Cardiology, Our Lady’s Children’s Hospital, Crumlin, Dublin 12, Ireland

    Sophie Duignan, Aedin Ryan, Damien Kenny & Colin J. McMahon

  2. Simulation Centre, Department Medical Education, Royal College of Surgeons Ireland, Dublin, Ireland

    Dara O’Keeffe

  3. School of Medicine, University College Dublin, Belfield, Dublin 4, Ireland

    Colin J. McMahon

Authors
  1. Sophie Duignan
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  2. Aedin Ryan
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  3. Dara O’Keeffe
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  4. Damien Kenny
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  5. Colin J. McMahon
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Correspondence to Colin J. McMahon.

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Duignan, S., Ryan, A., O’Keeffe, D. et al. Prospective Analysis of Decision Making During Joint Cardiology Cardiothoracic Conference in Treatment of 107 Consecutive Children with Congenital Heart Disease. Pediatr Cardiol 39, 1330–1338 (2018). https://doi.org/10.1007/s00246-018-1899-3

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  • DOI: https://doi.org/10.1007/s00246-018-1899-3

Keywords

  • Bias
  • Conference
  • Congenital heart disease
  • Decision making
  • Heuristics
  • Multidisciplinary