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. 2023 Nov 1;42(11):1408-1413.
doi: 10.1097/ICO.0000000000003159. Epub 2022 Oct 17.

Quantifying Clinicians' Diagnostic Uncertainty When Making Initial Treatment Decisions for Microbial Keratitis

Patrice M Hicks  1 , Karandeep Singh  2   3   4 , N Venkatesh Prajna  5 , Ming-Chen Lu  1 , Leslie M Niziol  1 , Miles F Greenwald  1 , Angela Verkade  1 , Guillermo Amescua  6 , Sina Farsiu  7 , Maria A Woodward  1   4 ; Corneal Ulcer Study Group
Collaborators, Affiliations

Quantifying Clinicians' Diagnostic Uncertainty When Making Initial Treatment Decisions for Microbial Keratitis

Patrice M Hicks et al. Cornea. .

Abstract

Purpose: There is a need to understand physicians' diagnostic uncertainty in the initial management of microbial keratitis (MK). This study aimed to understand corneal specialists' diagnostic uncertainty by establishing risk thresholds for treatment of MK that could be used to inform a decision curve analysis for prediction modeling.

Methods: A cross-sectional survey of corneal specialists with at least 2 years clinical experience was conducted. Clinicians provided the percentage risk at which they would always or never treat MK types (bacterial, fungal, herpetic, and amoebic) based on initial ulcer sizes and locations (<2 mm 2 central, <2 mm 2 peripheral, and >8 mm 2 central).

Results: Seventy-two of 99 ophthalmologists participated who were 50% female with an average of 14.7 (SD = 10.1) years of experience, 60% in academic practices, and 38% outside the United States. Clinicians reported they would "never" and "always" treat a <2 mm 2 central MK infection if the median risk was 0% and 20% for bacterial (interquartile range, IQR = 0-5 and 5-50), 4.5% and 27.5% for herpetic (IQR = 0-10 and 10-50), 5% and 50% for fungal (IQR = 0-10 and 20-75), and 5% and 50.5% for amoebic (IQR = 0-20 and 32-80), respectively. Mixed-effects models showed lower thresholds to treat larger and central infections ( P < 0.001, respectively), and thresholds to always treat differed between MK types for the United States ( P < 0.001) but not international clinicians.

Conclusions: Risk thresholds to treat differed by practice locations and MK types, location, and size. Researchers can use these thresholds to understand when a clinician is uncertain and to create decision support tools to guide clinicians' treatment decisions.

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Conflict of interest statement

Funding for this research was provided by the National Eye Institute (R01EY031033, M.A.W.) (P30 EY005722, S.F.) and a Research to Prevent Blindness Career Advancement Award (M.A.W.). The remaining authors have no funding or conflicts of interest to disclose. The funding support played no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Figures

Figure 1.
Figure 1.
Line plot displaying the median reported percentage risk of microbial keratitis (MK) at which a clinician would never or always treat with corresponding medications, stratified by MK type and the ophthalmologist’s practice location (US, United States; Intl, International).
See this image and copyright information in PMC

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