Biomedical
Post Hoc Bias in Treatment Decisions
Donald A. Redelmeier,
Peer Reviewed
Abstract
Importance A goal of health care is to reduce symptoms and improve health status, whereas continuing dubious treatments can contribute to complacency, discourage the search for alternatives, and lead to shortfalls in care. Objective To test a potential bias in intuitive reasoning following a marginal improvement in symptoms after a dubious treatment (post hoc bias).Design, Setting, and Participants Surveys eliciting treatment recommendations for hypothetical patients were sent to community members throughout North America recruited via an online survey platform in the early winter months of 2023 and 2024 and presented to health care professionals (pharmacists who were approached in person using a secret shopper technique) in the summer months of 2023.ExposureRespondents received randomized versions of surveys that differed according to whether vague symptoms improved or remained unchanged after a dubious treatment. Main Outcomes and Measures The primary outcome was a recommendation to continue treatment. Results In total, 1497 community members (mean [SD] age, 38.1 [12.5] years; 663 female [55.3%]) and 100 health care professionals were contacted. The first scenario described a patient with a sore throat who took unprescribed antibiotics; respondents were more likely to continue antibiotics after initial treatment if there was a marginal improvement in symptoms vs when symptoms remained unchanged (67 of 150 respondents [45%] vs 25 of respondents [17%]; odds ratio [OR], 3.98 [95% CI, 2.33-6.78]; P < .001). Another scenario described a patient with wrist pain who wore a copper bracelet; respondents were more likely to continue wearing the copper bracelet after initial care was followed by a marginal improvement in symptoms vs when symptoms remained unchanged (78 of 100 respondents [78%] vs 25 of 99 respondents [25%]; OR, 16.19 [95% CI, 5.32-19.52]; P < .001). A third scenario described a patient with fatigue who took unprescribed vitamin B12; respondents were more likely to continue taking vitamin B12 when initial treatment was followed by a marginal improvement in symptoms vs when symptoms remained unchanged (80 of 100 respondents [80%] vs 33 of 100 respondents [33%]; OR, 7.91 [95% CI, 4.18-14.97]; P < .001). Four further scenarios involving dubious treatments found similar results, including when tested on health care professionals. Conclusions and Relevance In this study of clinical scenarios, a marginal improvement in symptoms led patients to continue a dubious and sometimes costly treatment, suggesting that clinicians should caution patients against post hoc bias.
Key Questions
How does a marginal improvement in symptoms affect the likelihood of continuing a dubious treatment?
A marginal improvement in symptoms significantly increases the likelihood of continuing a dubious treatment. For example, in the antibiotic scenario, 45% of respondents recommended continuing antibiotics when symptoms improved, compared to only 17% when symptoms remained unchanged[1].
Does post hoc bias influence treatment decisions across different clinical scenarios?
Yes, post hoc bias consistently influenced treatment decisions across various clinical scenarios. The study found similar results in cases involving antibiotics, sugar supplements, acupuncture, copper bracelets, horse shampoo, and vitamin B12 supplements[1].
Are both community members and healthcare professionals susceptible to post hoc bias in clinical decision-making?
Yes, both community members and healthcare professionals (pharmacists) were found to be susceptible to post hoc bias in clinical decision-making[1].
How does the magnitude of post hoc bias vary across different types of dubious treatments?
The magnitude of post hoc bias varied across different treatments. For example, the odds ratio for continuing treatment after symptom improvement was 3.98 for antibiotics, 22.77 for sugar supplements, and 23.30 for horse shampoo[1].
What are the potential implications of post hoc bias for patient care and health outcomes?
Post hoc bias can lead to continued use of dubious or ineffective treatments, potentially contributing to delayed diagnosis of serious underlying conditions, unnecessary costs, and adverse health outcomes. The study suggests that clinicians should caution patients against this bias to improve care[1].
