Introduction: Physicians caring for patients with silent cerebral infarction (SCI) face several diagnostic and therapeutic challenges. In situations with limited information or lack of guidelines, clinical decisions may be influenced by aversion to uncertainty (AU) defined as a tendency to prefer known over unknown risks.
Hypothesis: We hypothesize that physicians’ AU is associated with overutilization of diagnostic tests and influences therapeutic choices for patients with covert cerebrovascular disease.
Methods: Participating physicians were practicing neurologists with expertise in stroke care identified from WSO, CSC, VasCog and SORCan. Those who agreed to participate were sent an online questionnaire.
Participants randomly received 10 cases from a pool of 20 assessing perception of risk for later stroke and treatment preferences, with additional validated questions to quantitatively determine AU, and overconfidence. The questionnaire was completed online. A multivariable analysis was completed adjusting for age, years of experience, and annual volume of stroke patients.
Results: Of 252 initial participants, 35 (13.9%) were excluded for incomplete responses. Of 217 remaining participants for the analysis, 50% of participants expressed that uncertainty was troublesome with their diagnosis. AU was associated with greater recommendation of oral anticoagulants for a case-scenario with atrial fibrillation, CHADS 4 and microbleeds (OR 3.26; 95%CI 1.30-8.19), and with ordering more investigations for an asymptomatic cortical infarction (OR 2.61; 95%CI 1.17-5.83). AU was also associated with recommending tPA or endovascular treatment for a 72 year old woman presented within 4 hours with an NIHSS 6-7 and asymptomatic microbleeds, but otherwise no other contraindication (OR 3.32; 95%CI 1.19-9.27).
Conclusion: Aversion to uncertainty is common among practicing stroke neurologists. AU was associated with ordering more investigations and more appropriate recommendations for oral anticoagulation or revascularization when indicated. The present study has practical implications, as aversion to uncertainty may be associated with a more vigilant practice.