Source/Disclosures
Disclosures: Saposnik reports receiving support from the Heart and Stroke Foundation Career Scientist Awards following an open peer-reviewed competition. Saposnik also reports receiving personal compensation for consulting or CME activities from Celgene, Hoffman LaRoche and Servier Canada. Please see the study for all other authors’ relevant financial disclosures.
December 21, 2020
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‘Traffic light’ educational intervention reduces therapeutic inertia among neurologists

Source/Disclosures
Disclosures: Saposnik reports receiving support from the Heart and Stroke Foundation Career Scientist Awards following an open peer-reviewed competition. Saposnik also reports receiving personal compensation for consulting or CME activities from Celgene, Hoffman LaRoche and Servier Canada. Please see the study for all other authors’ relevant financial disclosures.
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An educational intervention reduced therapeutic inertia, as measured by pupil dilation, among neurologists, suggesting that autonomic arousal shows how clinicians deal with uncertainty in therapeutic decision-making.

The educational intervention employed the traffic light system, which uses an established set of associations between traffic light colors and indications to stop or proceed.

Participant
Researchers measured pupil dilation to assess the impact of the intervention on therapeutic inertia.
Gustavo Saposnik
Gustavo Saposnik

“Most treatment decisions are made under uncertainty. We wanted to understand how physicians handle uncertainty when making live therapeutic decisions,” Gustavo Saposnik, MD, MPH, PhD, associate professor of neurology at the University of Toronto, staff neurologist at St. Michael’s Hospital and director of the Stroke Outcomes & Decision Neurosciences Research Unit at the Li Ka Shing Knowledge Institute, told Healio Neurology. “Participants were exposed to either the traffic light system (TLS) or usual care. Our educational intervention applied an innovative strategy in medical decision-making: taking the advantage of an existing color-coded brain system pathway that couples a warning sign (ie, red color of the traffic light) with an action (eg, treatment escalation or intensification).”

Therapeutic inertia refers to that escalation of therapy, or failure to escalate therapy, according to the study findings. Saposnik and colleagues examined whether the TLS educational intervention reduced therapeutic inertia by decreasing autonomic arousal response, as measured by pupil dilation, which served as a proxy measure for physicians’ response to uncertainty while making treatment-related decisions.

The study comprised 34 neurologists from 15 outpatient MS clinics in academic and community centers across Canada (mean age, 44.6 years; 38.3% women). The researchers randomly assigned participants to receive the educational TLS intervention or usual care; the latter group served as the control group.

Participants in the TLS intervention group listened to 20 audio-recorded simulated case scenarios while the researchers evaluated pupil responses with eye trackers. Saposnik and colleagues calculated autonomic arousal via pupil dilation in periods when the simulation provided critical information. This information included clinical data (first period [T1]), neurological status (T2) and MRI data (T3), according to the study results. The researchers analyzed data from September 2018 through March 2020.

Half of the participants in the study displayed therapeutic inertia, Saposnik and colleagues found, which correlated with increased pupil dilation. With every additional standard deviation of pupil dilation, the odds of therapeutic inertia increased by 51% for T1 (OR = 1.51; 95% CI, 1.12-2.03), by 31% for T2 (OR = 1.31; 95% CI, 1.08-1.59) and by 49% for T3 (OR = 1.49; 95% CI, 1.13-1.97).

The TLS intervention significantly decreased therapeutic inertia (risk reduction = 31.5%; 95% CI, 16.1% to 47%). Autonomic arousal responses mediated 29% of the impact of the educational intervention on therapeutic inertia, according to the study results.

“Pupil enlargement in doctors was associated with suboptimal decisions (eg, not increasing treatment when recommended by best practice recommendations),” Saposnik said. “An educational intervention (applying the TLS) helped doctors identify situations with risk for MS progression, thus changing for more beneficial treatments. Our intervention showed a reduction in the arousal response (stress response) to uncertainty by facilitating optimal treatment decisions aligned with the current best practice guidelines in Canada and worldwide.”

The researchers found that 1 out of 4 or 5 decisions made by clinicians are suboptimal, according to Saposnik, a factor that could lead “greater and faster disability progression” and reduced quality of life for patients with MS. However, the TLS intervention effectively reduced suboptimal decisions in MS care.

The next steps in this research involve studies that use functional MRI to examine the specific areas of the brain involved in the decision-making process of therapeutic inertia and optimal choices, Saposnik continued.

“We need to overcome knowledge and knowledge-to-action gaps in medical education. Given the lack of formal training in risk management and decision-making in the medical curriculum of most medical schools, it is critical to implement mandatory courses to overcome these limitations in the same way issues with diversity biases affect patient care.”