592 - The Associations Between Clinical Uncertainty and Practice Intensity Among Pediatric Inpatient Providers

Publication Number: 2577.592

Dena M. Lowing, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, United States; Marcella H. Boynton, University of North Carolina at Chapel Hill, Hillsborough, NC, United States; Neal A. deJong, University of North Carolina at Chapel Hill School of Medicine, Carrboro, NC, United States; Lindsay Chase, UNC, Chapel Hill, NC, United States; Wade Harrison, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, United States

Background: Medical decision-making under conditions of uncertainty can arise from clinician inexperience, clinical ambiguity, or evidence limitations. Clinicians vary in their response to uncertainty, which may influence management decisions and resource use. Prior studies link lower tolerance of uncertainty with higher practice intensity (e.g., increased testing or treatment), but few examined these relationships in pediatrics or explored how risk perception and confidence contribute.

Objective: To examine relationships between tolerance of uncertainty and practice intensity among pediatricians.

Design/Methods: This cross-sectional, vignette-based survey included pediatric and internal medicine-pediatric residents, pediatric hospital medicine (PHM) fellows, and PHM faculty at 8 academic institutions. The anonymous online survey comprised: (1) demographic characteristics; (2) validated subsets of the Need for Cognitive Closure (NFCC) and the Physicians' Reactions to Uncertainty (PRUS) scales assessing tolerance of uncertainty; and (3) four vignettes representing common pediatric scenarios (pneumonia, neurostorming, febrile infant, cellulitis) (Figure 1). Participants were randomized to 1 of 2 versions of each vignette (lower vs. higher clinical ambiguity) and received two of each level overall. For each vignette, participants selected 1 of 3 management options varying in intensity and rated their worry (5-point Likert), perceived risk of serious pathology (0-100%), and confidence (5-point Likert). Multilevel multinomial logistic models controlling for ambiguity (fixed effect) and respondent (random effect) assessed associations between tolerance of uncertainty and practice intensity or worry.

Results: Response rate was 21% (213/1001). Similar to prior studies, lower tolerance of uncertainty was associated with female gender, younger age, and trainees (Table 1). Lower tolerance of uncertainty and higher clinical ambiguity were independently associated with increased worry and greater practice intensity (Table 2). Clinicians were 6% and 13% more likely to choose the most intensive management option (vs. least intensive) for every 1-point higher score on the PRUS and NFCC, respectively. Analyses examining risk assessment and confidence are ongoing.

Conclusion(s): Among pediatricians, lower tolerance of uncertainty and greater clinical ambiguity were associated with greater worry and more intensive management decisions. Understanding the diverse drivers of decision-making, both situational and personal, is crucial to developing strategies that support clinicians and promote high-value care.

Figure 1: Conceptual Model
A conceptual model of medical decision-making including personal and situational influences. Practice intensity is defined as the relative aggressiveness of medical decisions reflected in the extent of diagnostic testing, scope of therapeutic interventions, and thresholds for admission or discharge.

Table 1: Demographic Characteristics and Tolerance of Uncertainty
Abbreviations: Physicians' Reactions to Uncertainty Scale (PRUS), Need for Cognitive Closure (NFCC). P-values were calculated using ANOVA with a significance level of 0.05. Scores range from 1-30 (PRUS) or 1-25 (NFCC) with higher scores indicating lower tolerance of uncertainty.

Table 2: Multilevel Multinomial Logistic Models
Abbreviations: Physicians' Reactions to Uncertainty Scale (PRUS), Need for Cognitive Closure (NFCC), Relative Risk Ratio (RRR)
1. Multilevel multinomial logistic models assessing the association of tolerance of uncertainty with practice intensity or worry controlling for ambiguity (fixed effect) and respondent (random effect). Model 1 measures tolerance of uncertainty using the PRUS whereas Model 2 uses NFCC.
2. Scores range from 1-30 (PRUS) or 1-25 (NFCC) with higher scores indicating lower tolerance of uncertainty.
3. Higher vs. lower clinical ambiguity.