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P. Bories et al.
Table 3. Characteristics associated with belonging to the intensive care (IC) group. Results from the multivariate logistic regression among the 210 clinicians for whom complete data of variable selected based on the bivariate analysis.*
Age (per additional year)
Aversion towards risks
Aversion towards uncertainty (for each 50 euro decrease) General attitude towards the risk regarding personal life Activity in AML pts. ≥60y/year
Gender among rational
OR [95% Confidence Interval]
1.00 [0.97 ; 1.03]
1.00 [0.99 ; 1.01] 1.17 [1.01 ; 1.37] 1.10 [0.95 ; 1.29] 0.98 [0.96 ; 0.99]
P
0.757
0.875 0.043 0.208 0.032
0.865
0.01
0.035
Men ref.
No
Interaction term = difference between irrational
effect among women and men
0.93 [0.39 ; 2.20] Yes ref.
Women
Expected utility among men
3.45 [1.34 ; 8.85]
0.253 [0.07 ; 0.91]
OR: Odds Ratio; pts: patients; AML: acute myeloid leukemia; ref: reference value. *Results of the parsimonious model constructed from a backward-stepwise-procedure (see the Methods section for details) which was initially additionally adjusted for clinicians’ general attitude regarding their own health and aversion towards risks.
ther and show that a behavioral characteristic such as uncertainty aversion is directly correlated with the clini- cian’s therapeutic choice. We evaluated physician behav- ioral characteristics with tools validated in behavioral eco- nomics. Although such tasks may be incentivized (paid for real) in experimental economics, we decided to use hypo- thetical incentives following Kahneman and Tversky (1979) who claimed that: “the method of hypothetical choices emerges as the simplest procedure by which a large number of theoretical questions can be investigated. The use of the method relies on the assumption that peo- ple often know how they would behave in actual situa- tions of choice, and on the further assumption that the subjects have no special reason to disguise their true pref- erences”. Concerns have been raised about the correlation between a clinician’s medical behavior and their uncer- tainty aversion as measured by economical tools in a non- domain-specific manner.36 Our study confirms, as previ- ously reported,17,18 that economic behavior and its under- lying psychological traits can predict medical behavior. Our cohort was globally risk-seeking and ambiguity- averse; 109 (51.9%) of the physicians did not conform with the EU model, which is in line with evidence in behavioral economics.37,38 Mean self-reported willingness to take risks was consistent with previous results but high- er for the patient’s health domain.39 This finding may be explained by the toxicity related to the intensive therapy that physicians are used to prescribe. We detected an interaction between physician’s gender and the Allais par- adox, with an impact of departures from the EU model on decision-making, in male physicians. Gender effect for risk and uncertainty attitudes is a well-established stylized fact in behavioral economics,40,41 albeit the impact of the interaction between gender and Allais paradox on MDM has, to our knowledge, never been documented empirical- ly.
Although our findings provide novel insights into the clinical debate pitting intensive versus low-intensity approaches for older patients with AML, we acknowledge that our study has limitations. The respondent panel was
representative of the surveyed French hematologist popu- lation in terms of gender, hierarchical status and geograph- ical area. Respondents more often belonged to academic centers than surveyed physicians, which can be explained by the French healthcare system’s organization for AML patients usually being oriented towards academic centers. Physicians were asked to recommend how to treat an AML patient in an experimental framework. We deliber- ately proposed clinical situations where patients had announced they would accept medical decisions, and patient choices did not appear in the vignettes. Since informed decision-making has emerged as the new nor- mative standard for health care,42 concerns about the increase in complexity provided by this mode of decision making have been raised.43 To encompass this increase in complexity, and presumably of uncertainty, physicians were asked to state which therapy they would ideally rec- ommend, irrespective of the patient’s choice. We also evaluated individual clinician’s choices, whereas multidis- ciplinary team (MDT) decision-making is currently the standard of care in cancer. Even though a treatment plan devised by an MDT may differ from that of a single physi- cian, it is noteworthy that the MDT constitutes an area of exchange between healthcare professionals where they may clearly state which treatment they consider to be appropriate in any clinical situation. Another limitation is the construction of the clinical vignettes. We focused the proposed treatments on intensive, low-intensity therapy and best supportive care, and did not propose any investi- gational drug or therapeutic strategy through clinical trial enrollment. We anticipated this would have swayed the physicians’ answers in favor of trial participation. Even though clinical trial enrollment remains an ideal scenario for all AML patients, real-life data provided by the Netherland’s registry show that only a small number of patients over 60-years of age could benefit from such innovative strategy.44 We did not provide any potentially druggable molecular markers such as FLT3-ITD, NPM1 or IDH1/2 in the clinical scenarios, because, to date, a large proportion of French centers do not have access to these
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