judgement analysis of the clinical policies of cardiologists, care … · 2003-04-14 ·...

Judgement Analysis of the Clinical Policies of Cardiologists, Care of the Elderly Specialists and General Practitioners. This is a guide to the data sets produced from ESRC grant number R000238247 held by Ann Bowling (Principle Investigator), Clare Harries, Nigel Harvey, and Harry Hemingway. The full time researcher on the project was Damien Forrest. Each of 85 physicians (29 Cardiologists, 28 Care of the Elderly physicians, and 28 GPs) made patient management decisions on 72 computer presented hypothetical patients. See Method.txt for more details re the design. See Table1.txt for explanation re the levels of each variable. See lookphrasecodes.txt for coding of the phrases recorded in the lkcacegpesrc.dat file. See Materials.zip* for the interview schedule (checklists and graphs) used to create the subjective ratings dataset (importantesrc.dat) and subjective graphs datasets (graphsdataESRC.dat). See commentscode.doc for coding of the comments section of cacegpesrc.dat and cacegpselesrc.dat into decisions. There are five datasets for this project: All files (but one) are tab delineated datafiles. Missing data is specified by '*' The first two files are simple compilations of the data produced from the computer programme. The third and fourth files are simple compilations of the indications that variables influenced decisions, and the subjective graphs indicating how they influenced decisions. See materials.zip for the format of this. The fifth file is a summary of files 1 and 2, specifying which information was seen on each case, and what decisions were made. (1) cacegpesrc.dat = Computer task basic decisions: one datafile of 85 physicians' performance on 72 cases stacked in rows, each case containing information re independent variables and 25 dependent variables in columns. NB NOT ALL OF THIS INFORMATION WAS EXAMINED ON A CASE. SEE CACEGPLKESRC.DAT TO SEE WHAT WAS EXAMINED. This is a tab-delineated data file. The first line containss the names of the variables. Each row after that contains the information that was available (but not necessarily examined) for each hypothetical patient. Code = the physician's code. Those starting ca are cardiologists, those starting ce are care of the elderly and those starting gp are General Practitioners. Trial = the trial number on which the hypothetical patient was seen by that physician. Caseno = The original case number of the patient. Image1 = The code of the image displayed as this hypothetical patient. SEE TABLE1.TXT FOR THE MEANING AND LEVELS OF OTHER VARIABLES.

(2) lkcacegpesrc.dat = Computer task information search: one datafile of 85 physicians' order of information search across the same 72 cases, again stacked in rows. Each line provides a continuous stream of data that indicates the trial number, followed by phrases and numbers. The phrase indicates which variable was looked at. The numbers between each phrase indicate the time in seconds that elapse between examining each variable. SEE LOOKPHRASECODES.TXT TO TRANSLATE THESE CODES INTO VARIABLES. The lines correspond to the lines in cacegpesrc.dat (after the line of variable names). SEE CACEGPESRC.DAT FOR INFORMATION ON WHICH PHYSICIAN'S DATA CORRESPONDS TO WHICH ROW. (3) importantesrc.dat = Subjective influence ratings: one datafile of physicians' stated use of information, indicating which information had a significant influence on their decision making. Cardiologists asked about ETT, Chol, Presc, Revas, Risk and Ang (see below). Care of the elderly and GPs asked about ETT, Chol, Presc, Risk and Ref. One Care of the elderly physician (ce117) also holds a cardiology post and answered as a cardiologist. Data from 79 Physicians' (27 Cardiologists, 27 Care of the elderly and 25 GPs) statements of the influence of information on decision making are recorded. 1 = stated as influential, 0 = stated as not influential. Code = the physician's code. Those starting ca are cardiologists, those starting ce are care of the elderly and those starting gp are General Practitioners. Variable = the variable being assessed as influential (list able to be added to by physician therefore varies somewhat between physicians) ETT_CR = Influencing the decision to order an exercise tolerance test (Cued recall) ETT_FR = Influencing the decision to order an exercise tolerance test (Free recall) Chol_CR = Influencing the decision to order a cholesterol test (Cued recall) Chol_FR = Influencing the decision to order a cholesterol test (Free recall) Presc_CR = Influencing the decision to prescribe a statin (lipid lowering drug) (Cued Recall) Presc_Fr = Influencing the decision to prescribe a statin (lipid lowering drug) (Free Recall) Revas_CR = Influencing the decision to revascularise the patient (Cued recall) Revas_FR = Influencing the decision to revascularise the patient (Free recall)

Risk_CR = Influencing the judgment of the risk of coronary heart disease (Cued recall) Risk_Fr = Influencing the judgment of the risk of coronary heart disease (Free recall) Ang_CR = Influencing the decision to order an angiogram (Cued recall) Ang_FR = Influencing the decision to order an angiogram (Free recall) Ref_CR = Influencing the decision to refer to a cardiologist (Cued recall) Ref_FR = Influencing the decision to refer to a cardiologist (Free recall) (4) graphsdataESRC.dat = Subjective graph plots: one datafile of physicians' plots of the functional relationship between information and their decisions. 81 physicians' (28 cardiologists, 27 care of the elderly, 26 GPs) subjective graph plots of the relationship of independent variables on decisions. Cardiologists asked about ETT, Chol, Presc, Revas, Risk and Ang (see below). Care of the elderly and GPs asked about ETT, Chol, Presc, Risk and Ref. One Care of the elderly physician (ce117) also holds a cardiology post and answered as a cardiologist. The points plotted by physicians to indicate probability of each decision for each level of a variable. Plotted for cues indicated as being influential BUT data missing where time was limited. Code = the physician's code. Those starting ca are cardiologists, those starting ce are care of the elderly and those starting gp are General Practitioners. Variable = the variable's influence being plotted Level = the level of each variable. NB Ethnicity incorporates place of birth risk (POBRisk) Risk = Judgment of risk of coronary Heart Disease Presc = Decision to prescribe of statin (lipid lowering drug) Revasc = Decision to Revascularise (e.g. CABG) ETT = Decision to do a Exercise tolerance test Chol T = Decision to do a Cholesterol test Ang = Decision to order an angiogram Ref = Decision to refer to a cardiologist. (5) cacegpselesrc.dat = Recoding of files 1 and 2 (cacegpesrc.dat and lkcacegpesrc.dat). 85 physicians' decision making over 72 cases. Information not viewed coded as missing. Comments unpacked into decision variables. See Table1.dat for explanation of variables and their levels. see Commentscode.doc for explanation of unpacking of comments into decisions.

*Guide to materials.zip. Materials.zip contains the interview schedules for cardiologists, care of the elderly physicians and General Practitioners (CI.pdf, ECI.pdf and GPI.pdf respectively). It also contains the empty graphs for the physician to fill out to indicate how their decision making was influenced by information for each of several types of decision and for several types of information.

Judgement Analysis of the Clinical Policies of Cardiologists, Care of the Elderly Specialists and General Practitioners. This is a guide to the data sets produced from ESRC grant number R000238247 held by Ann Bowling (Principle Investigator), Clare Harries, Nigel Harvey, and Harry Hemingway. The researcher employed on the project was Damien Forrest. DESIGN This was an idiographic study designed to look at the information search and use by individual physicians for hypothetical patients in middle to old age presenting with chest discomfort. Each of these patients had "Suspected angina" written in their patient notes. The 72 hypothetical patients consisted of four photographic examples of people in each condition of a sex (Male, Female) x age-group (Middle-aged, old, very-old) x ethnic group (Asian, White, Black) design. In addition to these variables, participants could seek out 73 different types of information through 64 different requests corresponding to asking the patient, examining the patient, checking the patient's notes and ordering tests. Thirty-five pieces of information (labelled C on Table 1) were constant across cases and the same piece of information was always presented in the same way. Six further pieces of information (labelled RC on Table 1) varied only within a normal range across cases and were therefore categorically constant. Thirty-two pieces of information (R on table 1) were selected at random from a preset range that would include levels associated with heart problems and levels not associated with heart problems. For some of these the information presented for each level of the variable depended upon the patient's sex, for others the information presented depended on ethnic origin, for another, the information depended upon allergies. The levels of three (varying) pieces of information depended upon levels of other variables. Not being in employment occurred at random for 6% of the population below 63, but all patients older than 62 were retired. Only those patients who presented with chest discomfort with the character of shortness of breath, had shortness of breath. Those patients who used to smoke, or had smoked for years could have given up between 1 and 9 years ago, whereas those who were smokers had a time since quit of zero years. PARTICIPANTS were physicians working in the UK. 28 of these were General Practitioners, 29 were Cardiologists and 28 were Care of the Elderly specialists. PROCEDURE Each participant completed the computer-presented tasks in their usual work location over several (on average 3) one-hour sessions. In a fourth session they completed a semi-structured interview in which they filled out graphs indicating how information available had influenced their decision-making. At the end of this they received feedback on their performance on the task. This consisted of a paper document outlining their information selection and use in relation to cardiac decisions and it included graphical displays similar to the ones the physician had just completed. The computer task and interviews were all administered by DF ON SCREEN INSTRUCTIONS WERE IDENTICAL FOR ALL PARTICIPANTS: You will be presented with approximately 36 patients in this session. The goal for each case is to make a patient management decision. For example, you might prescribe medication, offer lifestyle advice, refer the patient, make a later appointment, or any combination of these. There are a number of informational sources available to you to aid in your decision. For example, you are able to ask (the patient) questions, conduct a physical examination, read the case notes

and order available tests. However, your time is valuable and you have a large number of patients to see. You are encouraged to seek only as much information as you feel is necessary to make your decision. At the start of the task the participant was offered a chance to go through an example case. For each case, the participant verbally requested information about the patient and the result of this request appeared on the screen. Keyboard short-cuts operated by an experimenter (DF) were used to display information on a laptop computer. The purpose of this was (a) to avoid prompting after exposure to items on menus operated by the participant themselves and (b) to allow the participant to request information in their usual manner. Patient management decisions, (treatment, referral, new appointment etc) were also entered into the computer by DF using a keyboard shortcut and he used the keyboard to enter their comments and specifications into the Participant's textbox. More than one patient management decision could be made but a participant could not proceed to the next case until at least one decision had been made. Altogether 72 cases were viewed. STIMULI consisted of 72 different hypothetical cases. At the start of each case the top bar of the computer screen was labelled with the case number. The screen displayed a black and white photograph of the head of the 'patient' in the top left-hand corner. On the right of this was a large text box - the patient's verbalisation textbox. At the start of the case, this contained one of five phrases summarising that patient's presenting complaint - the character of chest discomfort they were experiencing. Below these from the left were four rectangular buttons labelled 'Ask patient', 'Examine patient', 'Patient notes', and 'Order tests'. Below these there were three drop down menu bars. The immediate contents of these were blank but they were labelled 'Treat', 'Refer' and 'Next appointment'. Below these menus at the bottom-left of the screen was a rectangular button labelled 'Help'. On the right of this was a large text box (the doctor's verbalisations textbox). This had a vertical scroll bar on the right hand side and was labelled 'Any other comments?'. On the bottom-right of the screen there was a rectangular button labelled 'Next case'. All buttons in the task were light yellow. The background was lilac. Responses to questions relating to ask patient, or examine patient appeared in the patient's verbalisation textbox. Questions relating to the patient notes opened up a separate window containing a graphical representation of file with tabs labelled Date of Birth, Family History, Current medication, Illness History, BMI, Allergies, Blood Pressure, Previous tests, Other information. Questions requesting tests opened up a new screen with the test results in. (without keyboard short cuts a file would first appear listing tests under the tabbed headings Cardiology, Endoscopy, Imaging, Blood tests.) PHOTOGRAPHS were obtained by DF using a digital camera and cream backboard. DF approached people in public places, in day centres and in workplaces. Those people who consented to be photographed were informed that the photograph was to be used in medical research and would remain anonymous bar information about the person's date of birth, sex and ethnic origin. They were offered the opportunity to give their address details for the sole purpose of being sent a copy of the photograph. They were given a tear off slip with the project details on and instructions to contact us at any time, should they wish their photograph to no longer be used. TEST RESULTS AND IMAGES were obtained from local hospitals and were selected to cover normal to severe test results. Images were available for Angiogram (6 different), 12 lead ecg (4 different), Thallium scan (4 different), Exercise tolerance test (5 different), Echocardiogram , Chest x-ray (male and female different), Abdominal ultrasound (male and female different), Barium swallow (one, normal), and CT scan (one, normal).

EXAMPLE CASE The photograph used for the example was always a 52 year old bearded Caucasian male (NH). This was never included in the main task. The example case was identical in appearance to the other cases except for the fact that the window bar was labelled 'Example case' and the 'Next case' button was green and labelled 'End example'. Semi-structured interview Cardiologists were asked about the factors influencing decisions to revascularise a patient, to order an angiogram, to order ETT, to prescribe a statin and to order a cholesterol test, and the factors influencing the judgment of the patient's risk of coronary heart disease. Care of the Elderly physicians and GPs were asked about the factors influencing decisions to refer a patient to a cardiologist to to order ETT, to prescribe a statin and to order a cholesterol test, and the factors influencing the judgment of the patient's risk of coronary heart disease. FREE RECALL: For each of the decisions and judgment (to order an angiogram, to order ETT, to order a Cholesterol test, to refer for revascularisation, to prescribe a statin, assessment of the risk of coronary heart disease) participants were asked to list the information that influenced their decision making on the computer task. CUED RECALL: Participants were then shown a list of 32 pieces of information that varied on the task, with indicators next to the information they had named already as influential for each decision. They were encouraged to identify any other factors that were influential. Risk of coronary heart disease, although implicit for each patient they had seen in the task, was included in this list. Graphical representation: For each of the factors that they had indicated were influential, participants were given a graph containing no data points. On this they plotted the likelihood of the decision for each level of the factor. Ethnicity levels included country of origin (e.g. England, Bangladesh), as well as a gross measure of ethnicity (ie. Black, White, Asian).

Judgement Analysis of the Clinical Policies of Cardiologists, Care of the Elderly Specialists and General Practitioners. This is a guide to the variables of the data sets produced from ESRC grant number R000238247 held by Ann Bowling (Principle Investigator), Clare Harries, Nigel Harvey, and Harry Hemingway. The following table contains the information describing each hypothetical patient. NB NOT ALL THIS INFORMATION WAS EXAMINED. Any other information requested was displayed as unavailable. SEE METHOD.TXT FOR ADDITIONAL INFORMATION. O = Orthogonal: Sex, Age Group and Ethnic Group formed a 2x3x3 within subject design. r = Variable level selected at random on running the programme. C = Variable level constant Rc = Variable level selected at random on running the programme but all levels fall within the normal range. DV = Dependent Variable Abbreviation Variable Name Type Levels Sex Sex O 2 1: Male, 2: Female Agegp Age group O 3 (1: 46-56, 2: 52-66, 3: 66-92) (Precise age and year of birth were available) age = age of the person portrayed in the image of the hypothetical patient. ageseen = age of the person when that information requested dob = Year of birth of the person portrayed in the image of the hypothetical patient. Ethnicity Ethnicity O 3 White, Black, Asian (see also pob) charac Character of chest pain R 1: "short of breath" 2: "a burning feeling" 3: "an aching feeling" 4: "a heavy feeling" 5: "this tight feeling" angio Coronary Angiogram R 1: "Normal LV function." "Normal coronaries." 2: "Good LV function." "Separate origin for LAD and circumflex." "LAD - minor disease only." "Circumflex - mild/moderate lesion in midcourse." "RCA - large vessel with no significant lesions."

3: "Good LV function." "LMS: LAD has severe midcourse discrete stenosis." "CX: normal." "RCA: normal." 4: "Good LV function with mild hypokinesis." "LMS - large normal." "LAD - multiple tight proximal lesions which also involve main diagonals. Distal portion of RCA fills retrogradely." "Circumflex - small vessel, large OM1 with a 60% proxial lesion." "RCA - large vessel with tight midcourse disease and then further disease leading to occlusion in distal vessel." 5: "Poor overall LV function with marked apical akinesis." "LMS - very short." "LAD - tight extremely proximal lesion and then multiple tight complex midvessel Large diagonal with mild early disease." "Circumflex - severely diseased proximally in large vessel." "RCA - small vessel with early/mid moderate disease." 6: "Good LV function." "LMS - very tight lesion." "LAD - multiple tight lesions in proximal vessel with good calibre distally." "Circumflex - tight proximal lesion with large distal vessel with only mild irregularity. Crossfills RCA retrogradely." "RCA - occluded proximally." ecg Resting 12 lead ecg R 1: "Normal SR, normal QRS axis. Patient is asympomatic." 2: "Normal SR, normal QRS axis. Shows non-specific ST-T changes." 3: "Normal SR, normal QRS axis. There is symmetrical T wave inversion in the anterior septal leads." 4: "Normal SR, normal QRS axis. Shows ST depression in all anterior leads."

thall Thallium scan R 1: "Homogeneous myocardial perfusion during Adenosin vasodilation. There is therefore no significant coronary obstruction and the risk of future coronary events is low." 2: "There is mild inferolateral inducible ischaemia suggesting a low likelihood of future coronary events." 3: "There is inducible ischaemia of the anterior wall, apex, inferior wall and septurn which is mild to moderate severity. The scan sugests a moderate risk of future coronary events." 4: "There is inferolateral ischaemia that is moderate to severe. The scan suggests a moderate to high risk of coronary events." ett Exercise ECG R 1: "Normal HR and BP response. Patient is asymptomatic and there are no significant ST changes." 2: "Patient is symptomatic; with no ST changes." 3: "Exercise test shows some ST depression." 4: "Exercise test shows downsloping ST depression in anterior leads." 5: "Exercise test shows marked horizontal downsloping ST depression in several leads." onset Primary onset of chest pain R 4: " without doing any physical activity. " 3: " just after I start any physical activity. " 2: " if I walk for a couple of hundred yards or if I exert myself too quickly. " 1: " if I push myself really hard or if I exert myself for a long period of time. " othonset Secondary onset of chest pain R 1: "Nothing."

2: "It sometimes comes on after I've eaten." 3: "It sometimes comes on when I get angry or frustrated."

4: "It sometimes comes on when I'm out in the cold."

duratn Duration of chest pain R 1: " a few seconds. " 2: " a few minutes. "

3: " about ten minutes. " 4: " about half an hour. " pshist History of presenting symptom

(chest pain) R 1: " 4 weeks or so" 2: " five months or so" 3: " ten months or so" toothache Toothache R 1: "No toothache."

2: "Yes, I've been having toothache."

fever Fever R 1: "No, I haven't had a fever."

2: "Yes, I've had a fever."

headache Headache R 1: "No, no headaches." 2: "Yes, I've had headaches."

sorethroat Sore throat R 1: "No, no sore throat." 2: "Yes, I've had a sore throat."

cough Cough R 1: "No, no cough." 2: "Yes, I've had a cough."

wtloss Weight loss R 1: "No." 2: "Yes." allergies Allergies R "Allergic to aspirin" (5%) "No allergies."(95%) meds Medication R * dep allergies

1: "Isosorbide Dinitrate. " (20mg twice daily). 2: "Clopidogrel" (75ml)", Isosorbide Dinitrate" (20mg twice daily). OR "Aspirin" (75ml) ", Isosorbide Dinitrate" (20mg twice daily). 3: "Clopidogrel" (75ml) ", Isosorbide Dinitrate" (20mg twice daily). ", Nifedipine" (10mg twice daily, 50% OR 20mg twice daily, 50%). OR "Aspirin" (75ml) ", Isosorbide Dinitrate" (20mg twice daily). ", Nifedipine" (10mg twice daily, 50% OR 20mg twice daily, 50%). 4: "Clopidogrel" (75ml) ", Isosorbide Dinitrate" (20mg twice daily). ", Atenolol" (25mg once daily, 50% OR 100mg once daily, 50%). OR "Aspirin" (75ml) ", Isosorbide Dinitrate" (20mg twice daily). ", Atenolol" (25mg once

daily, 50% OR 100mg once daily, 50%). 5: "Isosorbide Dinitrate" (20mg twice daily). ", Atenolol" (25mg once daily, 50% OR 100mg once daily, 50%) ", Nifedipine" (10mg twice daily, 50% OR 20mg twice daily, 50%).

levCA = The level of calcium antagonists (nifedipine). 0: = 0,

1: 10mg twice daily,

2: 20mg twice daily levBB = The level of betablockers. 0: 0, 1: 25mg once daily, 2: 100mg once daily levnit = The level of isosorbide Dinitrate. 1: 20mg twice daily, 2: 20mg twice daily physactive Physically active R 1: "Highly active lifestyle."

2: "Moderately active lifestyle."

3: "Inactive lifestyle." diet Diet R 1: "Balanced diet." 2: "High fat diet." alcohol Alcohol R * depending upon sex 1: "Teetotal." 2: "Drinks moderately - less than 15 units per week." (M)

"Drinks moderately - less than 10 units per week." (F) 3: "Drinks heavily - 20-30 units per week." (M) "Drinks heavily - 14-20 units per week." (F) 4: "Drinks very heavily - more than 30 units per week." (M) "Drinks very heavily - more than 20 units per week." (F)

homesit Home situation R 1: "Lives alone." 2: "Lives with partner/spouse."

3: "Lives with relatives." smokes Smokes R 1: "Non smoker" 2: "Used to smoke." 3: "Smoked for years." 4: "Smoker - one packet a day" quittime Time since quit R *Depends on Smokes "Non smoker" quittime = 11

"Used to smoke." or "Smoked for years." (1-9 years ago picked at random) "Smoker - one packet a day" quittime = 0 bp Blood pressure R 1: "25/85" 2: "140/95" 3: "155/95" 4: "165/100" timebp Time since last bp R 1: within the last 6 months (day chosen randomly from 182)

2: 6 months to a year ago (day chosen randomly from 182)

3: a year to 18 months ago (day chosen randomly from 182) fh Family history R 1: "Family history of ischemic heart disease."

2: "None recorded." bmi BMI R 1: "Underweight - BMI of " (17-20) 2: "Normal - BMI of " (21- 25)

3: "Overweight - BMI of " (26-30)

4: "Obese - BMI of " (31- 35)

POBRisk Cultural (risk) group & place of birth R * depending upon ethnicity 1: Low risk (England (W), Nigeria (B), India (A)) 2: Medium risk (Wales (W), England (B), Pakistan (A)) 3: High risk (Scotland (W), Carribean (B), Bangladesh (A))

Then place of birth picked at random from the 5 possibilities for each place of origin:

England = London, Bristol, Manchester, Birmingham, or Liverpool Wales = Swansea, Cardiff, Newport, Holyhead, or Bangor Scotland = Glasgow, Edinburgh, Dundee, Aberdeen or Inverness India = Delhi, Bangalore, Calcutta, Bombay or Mysore Pakistan = Karachi, Islamabad, Khairpur, Karachi or Lahore Bangladesh = Dhaka, Saidpur, Khulna, Rajshahi or Dhaka Caribbean = Trinidad, St Lucia, Montserrat, Jamaica, or Barbados Nigeria = Abujai, Lagos, Lagos, Kano or Asaba

job Job R 1 = "Architect." 2 = "Chemical engineer." 3 = "Civil engineer." 4 = "Mechanical engineer." 5 = "Statistician." 6 = "Chemist." 7 = "Optometrist." 8 = "Solicitor." 9 = "Economist." 10 = "Management consultant." 11 = "Psychologist."

12 = "Dentist." 13 = "Physiotherapist."

14 = "Commercial artist." 15 = "Author." 16 = "Computer programmer."

17 = "Building inspector." 18 = "Librarian." 19 = "Air traffic controller." 20 = "Actor." 21 = "Chiropodist."

22 = "Clothing designer." 23 = "Quality surveyor." 24 = "Accountant." 25 = "Photographer." 26 = "Sound engineer." 27 = "Retail cashier supervisor."

28 = "Retail sales assistant."

29 = "Security guard supervisor."

30 = "Petrol garage supervisor."

31 = "Telephone operator supervisor."

32 = "Cameraman." 33 = "Sales worker, motor vehicles."

34 = "Police constable." 35 = "Estate agent." 36 = "Police sergeant." 37 = "Dry cleaner."

38 = "Tailor, supervisor." 39 = "Shoe repairer." 40 = "Carpenter." 41 = "Toolmaker." 42 = "Painter and decorator."

43 = "TV repairer." 44 = "Bus driver." 45 = "Coach driver." 46 = "Goldsmith."

47 = "Plumber." 48 = "Butcher." 49 = "Postman." 50 = "Traffic warden."

51 = "Gardener." 52 = "Embroiderer." 53 = "Bus conductor." 54 = "Security guard."

55 = "Store keeper." 56 = "Waiter." 57 = "Barperson." 58 = "Storekeeper."

59 = "Cleaner." 60 = "Roadsweeper." 61 = "Kitchen porter." 62 = "Car park attendant."

63 = "Window cleaner."

64 = "Railway station worker."

65 = "Construction worker."

66 = "Lift attendant." 67 = "Sewage plant attendant."

68 = "Civil engineering labourer."

69 = "Textiles labourer." 70 = "Goods porter." 71 = "Driver's mate." 72 = "Refuse collector." unempl Unemployed and retired R *Depends on age If age> 62 then "Retired " If age<63 then "Unemployed " (6%), employed (94%) Illlevel Number of illnesses in notes R 0 illnesses other than suspected angina (and hypertension)

4 illnesses other than suspected angina (and hypertension)

8 illnesses other than suspected angina (and hypertension)

Selected at random from "Asthma" "Hay fever" "Ear infection" "Eczema-dermatitis" "Herpes zoster" "Acute bronchitis" "Anaemia" "Diabetes: Type I" (75%) ‘Generic insulin’ OR "Diabetes: Type II" (25%) ‘Gliclazide, Metformin’ "Anxiety" "Constipation" "Acute diarrhoea" "UTI" "Back pain" "Migraines"

"Acute tonsilitis" "Arthritis" "Indigestion" "Insomnia" "Depression" chotot Cholesterol R 1: LIPID PROFILE Cholesterol 3.7 [2.3- 5.2] mmol/L

Triglyceride 1.3 [0.4-1.8] mmol/L

HDL Cholesterol 1.5 [0.9-1.4] mmol/L

LDL Cholesterol 1.6 [0-3.5] mmol/L

2: LIPID PROFILE

Cholesterol 4.9 [2.3- 5.2] mmol/L

3: LIPID PROFILE Cholesterol 6.5 [2.3- 3.5] mmol/L

HDL Cholesterol 0.6 [0.9-1.4] mmol/L LDL Cholesterol 6.5 [0-3.5] mmol/L

chopres = Whether or not there were cholesterol test results in the patient's notes. 0: No, 1: Yes. choltest = cholesterol test in notes (levels as chotot) chollevel = cholesterol test just

obtained (levels as chotot)

Shortness of breath R *As indicated in character of chest discomfort

Current diagnosis C *Dep current meds "Angina" or "Suspected angina and hypertension" if meds level >=3 tape 24 hour tape C 5 "24 hour tape results: No abnormalities." x-ray C "X-ray results: No abnormalities."

Drugs misuse C No substance misuse Location of chest pain C Centre of chest Radiation Radiate C No

Worsening C Not particularly Preferences C Don't mind Ankle swelling C None Dizziness C None

Fainting C No Anxious C Not particularly Depressed C Not particularly Gastric problems C None Indigestion or heartburn C None Jawache C None Nausea or vomiting C No Neck, back or abdominal pain C No Palpitations C No Sweating C No Operations C No Jugular venus pressure C Not raised Temperature C Normal Lungs sound C Normal Heart sounds C Normal Physical exam C Normal abdomen Palpate liver C Normal Eyes C "No abnormalities." Muscle tenderness in chest wall C "No muscle tenderness in chest wall." Abdominal MRI C "Comments: Normal kidneys, para-aortic area and upper abdomen. No evidence of collections." Abdominal ultrasound C "Comments: Normal liver, normal spleen. No lymphadenopathy identified. Normal kidneys and pancreas."

Barium swallow C "Comments: Barium flows freely down the oesophagus with no evidence of hold up or mucosal irregularity. Barium also outlines the stomach normally. The duodenal cap also looks normal with no evidence of scarring or ulcer formation."

Biliary tract endoscopy test C "These are the biliary tract endoscopy results." "No abnormalities found."

Gastrointestinal endoscopy test C "Endoscopy of the gastrointestinal tract: Results show normal function."

CTscan C "Comments: No axilary or mediastinal abnormality is seen. The lung fields are clear."

Echocardiogram Rc "Echocardiogram: Results show full and normal wall motion." See septum to ejection - varied within normal range

Glucose test Rc Glucose and HbA1 varied within normal range

Glucose " [4.2-5.8] mmol/L", HbA1 " [4.0-6.0] %Total Hb."

FBC test Rc HB, rbc, hct, mcv, mch, mchc, rdw, plt, mpv, wbc all varied within normal ranges (depends on sex) HB: "[13.0-17.0]" (M), "[11.5-15.5]" (F), rbc: "[4.40-5.80]" (M), "[3.95- 5.15]" (F), hct: "[0.37- 0.50]" (M), "[0.33-0.45]" (F), mcv: "[80.0-99.0]", mch: "[26.0-33.5]", mchc: "[30.0-35.0]", rdw: "[11.5-15.0]", plt: "[150- 400]", mpv: "[7.0-11.0]", wbc: "[4.0-11.0]"

Pulse Rc Normal 60-90 beats per minute Renal/Liver profile Rc Urea, Creatinine, Sodium, Potassium, Bilirubin, Alanine, Phosphatase, Albumin each varied within normal range. Urea: [3.5 - 7.0] mmol/L, Creatinine: [70-105] mmol/L, Sodium: [138-142] mmol/L, Potassium: [3.8 - 4.8] mmol/L, Bilirubin: [5-15] mmol/L, Alanine: [10-45] U/L, Phosphatase: [40-100] U/L, Abumin: [38-48] g/L Exact date of birth Rc Age in years of the person in the photograph plus a random month (of 12) then random date of that month. treat Treatment decisions DV -1: No treatment decision 0: Lifestyle advice (specified in comments)

1: Prescription (specified in comments) 2: Invasive procedure (specified in comments)

3: Other treatment decision (specified in comments)

refer Referal decision DV -1: No referal decision 0: Cardiologist 2: Care of the elderly 3: Chest physician

4: Dermatologist 5: Dietician 6: ENT specialist 7: Gastroenterologist

8: General Physician 9: Gynaecologist 10: Nurse 11: Oncologist

12: Osteopathy 13: Physiotherapist 14: Psychiatrist 15: Rheumatologist 16: Urologist 17: Other (specified in comments) wait Decision to see later DV -1: No next appointment made 0: Few days 1: One week 2: Two weeks 3: Three weeks 4: One month 5: Six weeks 6: Two months 7: Three months 8: Four months 9: Six months 10: One year 11: Other (specified in comments) Comments = The typed in detailed decisions and comments made by the physician on this hypothetical patient THE VARIABLES BELOW ARE SIMPLY BASED ON CODING OF TREAT, REFER, WAIT AND THE COMMENTS (SEE COMMENTSCODE.DOC) refcardio Referal to a cardiologist DV 0: Not refered to a cardiologist,

1: Refered to a cardiologist

revascularisation DV 0: Nor revascularised, 1: Revascularised (e.g. CABG) angiotest Angiogram DV 0: Nothing, 1: Angiogram ordered lipidlowering DV 0: Nothing, 1: Statin or other lipidlowering drug prescribed cholook DV 0: Nothing, 1: Cholesterol test ordered ETTord DV 0: Nothing,

1: ETT ordered Advcardio DV 0: Nothing, 1: Advice of cardiologist sought RefGP DV 0: Not refered to a GP, 1: Refered to a GP lifestyle DV 0: No lifestyle advice given, 1: Lifestyle advice given Discussion DV 0: Nothing, 1: Explicit mention of discussion with patient. Onuspat DV 0: Nothing, 1: Onus on patient to come back - told to come back

if for example situation worsens refCE DV 0: Not refered to a Care of the Elderly physician, 1: Refered to a Care of the Elderly physician refother DV 0: Not refered to other, 1: Refered to another professional (other than cardiologist, GP or care of the elderly) ace DV 0: Nothing, 1: ACE inhibitor prescribed alpha DV 0: Nothing, 1: Alpha blocker prescrbed aspir DV 0: Nothing, 1: Aspirin prescription changed potass DV 0: Nothing, 1: Potassium channel activator prescribed beta DV 0: Nothing, 1: Beta blocker prescription changed calcium DV 0: Nothing, 1: Calcium channel blocker prescription changed diuretic DV 0: Nothing, 1: Diuretic prescribed nitra DV 0: Nothing, 1: Nitrate prescription changed GTN DV 0: Nothing, 1: GTN prescribed allhtpre DV 0: Nothing, 1: Any heart related prescription prescribed or changed lungpres DV 0: Nothing, 1: Lung related drug prescribed stomachpres DV 0: Nothing, 1: Stomach related drug prescribed allotherpres DV 0: Nothing, 1: Lung or stomach drug prescribed (non-cardiac) monitor DV 0: Nothing, 1: New appointment suggested (wait indicated)

Variable Text in lkcacegpesrc.dat file 1 Exact Age How old are you? n1 2 Character of chest pain Describe the feeling. Remind me, what's the problem? 3 Coronary Angiogram Angio Coronary Angiogram 4 Resting 12 lead ecg ECG Resting (12 lead) ECG 5 Thallium scan Thallium scan Thallium 6 Exercise ECG ETT Exercise ECG 7 Primary onset of chest pain What brings the feeling on? 8 Secondary onset of chest pain What else brings the feeling on? 9 Duration of chest pain How long does it take to go away? 10 History of presenting symptom (chest pain) How long have you had it? 11 Toothache Toothache? 12 Fever Fever? 13 Headache Headache? 14 Sore throat Sore throat? 15 Cough Cough? 16 Weight loss Weight loss? Weightloss? 17 Allergies Any allergies? n6 18 Current (Coronary) Medication Current medication? qmeds n3 19 Physically active Physical activity? 20 Diet Diet? 21 Alcohol Alcohol? 22 Home situation Home circumstances? 23 Smokes Tobacco use? Tobacco? 24 Time since quit How long ago did you give up? 25 Blood pressure Blood pressure 26 Last bp Have you had high blood pressure in the past? n7 27 Family history Have you got a family history of heart disease? n2 28 BMI n5 29 Cultural (risk) group and place of birth Where are you from? 30 JobUnemployed and retired Job? 31 Number of illnesses in notes n4 Previous Illnesses? 32 Cholesterol Bloods lipid Lipid profile n8 33 Shortness of breath Shortness of breath? 34 Diagnosis Why are you on this medication. 35 24 hour tape 24 hour tape tape 36 x-ray Chest X-ray Xray 37 Drugs misuse Substance abuse? 38 Location of chest pain Where is this feeling? 39 Radiate Does the feeling radiate to anywhere else? 40 Worsening Has it been getting worse? 41 Preferences Have you got any preferences regarding treatment? 42 Ankle swelling Ankle swelling? 43 Dizziness Dizziness? 44 Fainting Fainting? 45 Anxious Feeling anxious? 46 Depressed Feeling depressed? 47 Gastric problems Gastric problems? 48 Indigestion or heartburn Indigestion or heartburn? 49 Jawache Jaw ache? Jawache? 50 Nausea or vomiting Nausea or vomiting? 51 Neck, back or abdominal pain Neck or back or abdominal pain? Neck, back or abdominal pain? 52 Palpitations Palpitations? 53 Sweating Sweating? 54 Operations Operations? 55 Jugular venus pressure Jugular venus pressure 56 Temperature Temperature 57 Lungs sound Check lungs 58 Heart sounds Listen to heart

59 Physical exam (Gastrointestinal) Examine patient 60 Palpate liver Palpate liver 61 Eyes Eyes 62 Muscle tenderness in chest wall Muscle tenderness in chest wall 63 Abdominal MRI Abdominal MRI MRI 64 Abdominal ultrasound Abdominal Ultrasound USound 65 Barium swallow Barium swallow Barium 66 Biliary tract endoscopy test Biliary tract 67 Gastrointestinal endoscopy test Endoscopy Gastrointestinal tract 68 CTscan Chest CT CTScan 69 Echocardiogram Echo Echocardiogram 70 Glucose test Bloods glucose Glucose 71 FBC test Bloods FBC FBC 72 Pulse Pulse 73 Renal/Liver profile Bloods liver Renal/liver profile 74 Othercard ot Other cardiac test 75 Otherim ot Other imaging test 76 Otherqu ot Other question. qotherquestion 77 Othersymp ot Other symptoms? 78 Other ot Other 79 Otherinf ot n9

Text to code from Comments Broad categorical decision Categorical decision Advice AND NOT diet advice AND NOT lifestyle advice

Advice Cardiologist Advice cardiologist

adivce Advice Cardiologist Advice cardiologist advcie Advice Cardiologist Advice cardiologist advice Advice Cardiologist Advice cardiologist ADVICE Advice Cardiologist Advice cardiologist phone Advice Cardiologist Advice cardiologist PHONE Advice Cardiologist Advice cardiologist discuss with consult Advice Cardiologist Advice cardiologist Discuss with Occupational doctor about Driving

Advice Occupational doctor Advice other

ang_ Angiogram - Angiogram angi_ Angiogram - Angiogram angio Angiogram - Angiogram Angio Angiogram Angiogram ANGIO Angiogram - Angiogram chol Cholesterol test - Cholesterol test Chol Cholesterol test - Cholesterol test congrat Congratulate - Discussion GOOD! Congratulate - Discussion positive reinf Congratulate - Discussion DISC AND NOT ischarge AND NOT DISCHARGE

Discussion - Discussion

Discharge Discharge - DISCHARGE Discharge - ask Discussion - Discussion ASK Discussion - Discussion BHF Discussion - Discussion

councel patient Discussion - Discussion iscuss AND NOT discuss with Discussion - Discussion DISCUSS Discussion - Discussion eassu Reassure - Discussion REASSURE Reassure - Discussion _ET ETT - ETT ett ETT - ETT Ett ETT - ETT ECHO Echocardiogram - Echocardiogram thall Thallium - Thallium bruit Exam or test - Test cardio BP Exam or test Hypertension Test cardio bp Exam or test Hypertension Test cardio troponin Exam or test - Test cardiac blood gases Exam or test Bloods/asthma Test cardiac/asthma Ox sats Exam or test asthma/bloods Test cardiac/asthma CP Test Exam or test - Test cardiac ESR Exam or test - Test cardiac check urine Exam or test - Test other diabetic work up Exam or test Diabetes Test other endo? Exam or test Endocrinology Test other gamma Exam or test -liver Test other Gamma Exam or test -liver Test other glucose T T Exam or test - Test other Glucose TT Exam or test - Test other iron studies Exam or test -iron Test other ferritin Exam or test - iron Test other L F test Exam or test - Test other lft Exam or test - Test other

LFT Exam or test - Test other Lung Exam or test - Test other lung Exam or test - Test other lymph check Exam or test - Test other glucose Exam or test - Test other peak flow Exam or test -asthma Test other Peak flow Exam or test -asthma Test other PFT Exam or test -asthma Test other rectal Exam or test - Test other Resp test Exam or test -asthma Test other MS disorders Exam or test MS Test other t f t Exam or test - Test other T F T Exam or test - Test other t FT Exam or test - Test other T FT Exam or test - Test other tft Exam or test - Test other TFT Exam or test - Test other Thy Exam or test - Test other THY Exam or test - Test other thy Exam or test - Test other urine Exam or test - Test other URINE Exam or test - Test other VQ scan Exam or test -lung Test other check wheeze Exam or test Asthma Test other check about asthma Exam or test Asthma Test other check peak flow Exam or test Asthma Test other AA Lifestyle Alcohol Lifestyle alchol Lifestyle Alcohol Lifestyle lcohol Lifestyle Alcohol Lifestyle

drink Lifestyle Alcohol Lifestyle food Lifestyle diet Lifestyle B12 Lifestyle diet Lifestyle b12 Lifestyle diet Lifestyle diet Lifestyle diet Lifestyle Diet Lifestyle diet Lifestyle DIET Lifestyle diet Lifestyle folate Lifestyle diet Lifestyle eating Lifestyle diet Lifestyle fat Lifestyle diet Lifestyle salt Lifestyle diet Lifestyle sugar Lifestyle diet Lifestyle eight Lifestyle diet Lifestyle WEIGHT Lifestyle diet Lifestyle chair Lifestyle exercise Lifestyle xer Lifestyle exercise Lifestyle EXER Lifestyle exercise Lifestyle stairs Lifestyle exercise Lifestyle bandolier Lifestyle General Lifestyle ourd Lifestyle General Lifestyle BOURD Lifestyle General Lifestyle job Lifestyle General Lifestyle living Lifestyle General Lifestyle life Lifestyle General Lifestyle sm Lifestyle smoking Lifestyle SMOKING Lifestyle smoking Lifestyle smoking Lifestyle smoking Lifestyle 18 months Monitor - Monitor re-c Monitor - Monitor

follow Monitor - Monitor if not improved in two weeks increase Monitor - Monitor keep an eye Monitor - Monitor monitor Monitor - Monitor RE-CHECK Monitor - Monitor recheck Monitor - Monitor review Monitor - Monitor repeat Monitor - Monitor revie Monitor - Monitor REVIEW Monitor - Monitor review Monitor - Monitor dvise Onus patient - Onus patient come Onus patient - Onus patient persist Onus patient - Onus patient diary Onus patient - Onus patient patient to monitor Onus patient - Onus patient worse. Onus patient - Onus patient report Onus patient - Onus patient reprot Onus patient - Onus patient return Onus patient - Onus patient trial Prescription - albutamol Prescription Asthma Prescription other A2 antagonist Prescription Asthma Prescription other entolin Prescription Asthma Prescription other steroids Prescription asthma Prescription other aminophylline sr Prescription Bronchodilator Prescription other atacid Prescription Antacid Prescription other cimetidine Prescription Antacid Prescription other aviscon Prescription Antacid Prescription other

gavison Prescription Antacid Prescription other gavsicon Prescription Antacid Prescription other H2 Prescription Antacid Prescription other h2 Prescription Antacid Prescription other itidine Prescription Antacid Prescription other spirolactone Prescription Antacid Prescription other losec Prescription antiacid Prescription other PPI Prescription antiacid Prescription other amoxicillin Prescription stomach Prescription other ansoprazol Prescription antiacid Prescription other lanzoprozol Prescription antiacid Prescription other omeprazole Prescription antiulcer Prescription other metformin Prescription Diabetes Prescription other consider insulin Prescription Diabetes Prescription other paracetamol Prescription paracetamol Prescription other nicotine replacement Prescription smoking Prescription other zyban Prescription smoking Prescription other CHANGE Change meds - Change current heart meds hange AND NOT “any changes” AND NOT “advise of changes” AND NOT “advise if changes” AND NOT “report change”

Change meds - Change current heart meds

chnage Change meds - Change current heart meds decrease Change meds - Change current heart meds icnrease Change meds - Change current heart meds incr AND NOT increase exercise AND not exercise increase

INCREASE Change meds - Change current heart meds LA AND NOT LAD AND NOT LATER Change meds - Change current heart meds

mon sr Change meds - Change current heart meds mono Change meds - Change current heart meds optimise Change meds - Change current heart meds raise Change meds - Change current heart meds reduce AND NOT reduce alcohol AND NOT reduce weight AND NOT reduce drink

remove Change meds - Change current heart meds split Change meds - Change current heart meds stoip Change meds - Change current heart meds stop AND NOT “top smoking” Change meds - Change current heart meds Stop Change meds - Change current heart meds STOP AND NOT “smoking – STOP” Change meds - Change current heart meds up nitrates OR up atenolol Change meds - Change current heart meds ace Prescription ACE Prescription cardiac Ace Prescription ACE Prescription cardiac ACE Prescription ACE Prescription cardiac ACR Prescription ACE Prescription cardiac angiotensin2 (blocker) Prescription ACE Prescription cardiac candesarta Prescription ACE Prescription cardiac lisinopril Prescription ACE Prescription cardiac perindopiril Prescription ACE Prescription cardiac ramapril Prescription ACE Prescription cardiac ramipril Prescription ACE Prescription cardiac alpha blocker Prescription alpha blocker Prescription cardiac doxasocin Prescription alpha blocker Prescription cardiac heparin Prescription antithrombotic Prescription cardiac pirin Prescription Aspirin Prescription cardiac aspiirin Prescription Aspirin Prescription cardiac

ASPIRIN Prescription Aspirin Prescription cardiac aspirn Prescription Aspirin Prescription cardiac sprin Prescription Aspirin Prescription cardiac aspririn Prescription Aspirin Prescription cardiac clopid Prescription clopidogrel Prescription cardiac niconradil Prescription Potassium channel activator Prescription cardiac niconrandil Prescription Potassium channel activator Prescription cardiac nicoradil Prescription Potassium channel activator Prescription cardiac nicorandil Prescription Potassium channel activator Prescription cardiac saltalol Prescription …Beta blockers Prescription cardiac soltalol Prescription Beta blockers Prescription cardiac sotalol Prescription Beta blockers Prescription cardiac SOTALOL Prescription Beta blockers Prescription cardiac aten Prescription Betablockers Prescription cardiac Atenolol Prescription Betablockers Prescription cardiac ATENOLOL Prescription Betablockers Prescription cardiac ateolol Prescription Betablockers Prescription cardiac bb Prescription Betablockers Prescription cardiac Bb Prescription Betablockers Prescription cardiac BB Prescription Betablockers Prescription cardiac bisoprolol Prescription Betablockers Prescription cardiac carvedlol Prescription Betablockers Prescription cardiac metoprolol Prescription Betablockers Prescription cardiac propanalol Prescription Betablockers Prescription cardiac propanaolol Prescription Betablockers Prescription cardiac aml Prescription Calcium channel blocker Prescription cardiac _ca AND NOT cabg AND NOT car AND NOT can

Prescription Calcium channel blocker Prescription cardiac

CA Prescription Calcium channel blocker Prescription cardiac

CC Prescription Calcium channel blocker Prescription cardiac nif Prescription Calcium channel blocker Prescription cardiac NIFEDIPINE Prescription Calcium channel blocker Prescription cardiac dilt Prescription Calcium channel blocker Prescription cardiac verapamil Prescription Calcium channel blocker Prescription cardiac natrilix Prescription Diuretic (thiazide) Prescription cardiac indapamide Prescription Diuretic Prescription cardiac azide Prescription Diuretic - Prescription cardiac bendro Prescription Diuretic Prescription cardiac BENDROFLUIZIDE Prescription Diuretic Prescription cardiac burinex Prescription Diuretic Prescription cardiac frusemide Prescription Diuretic Prescription cardiac frusimide Prescription Diuretic Prescription cardiac GNT Prescription GTN Prescription cardiac GTM Prescription GTN Prescription cardiac gtn Prescription GTN Prescription cardiac GTN Prescription GTN Prescription cardiac GTT Prescription GTN Prescription cardiac imdur Prescription Nitrate Prescription cardiac imudr Prescription Nitrate Prescription cardiac dipyridamole Prescription Nitrates Prescription cardiac ismn 60 Prescription Nitrates Prescription cardiac iso Prescription Nitrates Prescription cardiac itrate Prescription Nitrates Prescription cardiac nittate Prescription Nitrates Prescription cardiac _st_ Prescription lipidlowering drug Prescription cardiac - ll Stain Prescription lipidlowering drug Prescription cardiac - ll statain Prescription lipidlowering drug Prescription cardiac - ll statiin Prescription lipidlowering drug Prescription cardiac - ll

tatin Prescription lipidlowering drug Prescription cardiac - ll STATIN Prescription lipidlowering drug Prescription cardiac - ll ibrate Prescription Lipid lowering Prescription cardiac - ll DAY HOSPITAL Refer Cardiologist Refer Cardio REFER Refer Cardiologist Refer Cardio apid Refer Cardiologist Refer Cardio efer AND NOT (refer to diet BUT NOT refer (optimise meds)) AND NOT diet control – refer AND NOT ipidologist refer AND NOT diet refer AND NOT refer to GP AND NOT no refer

Refer Cardiologist Refer Cardio

GP Refer GP Refer GP gp Refer GP Refer GP chest doc Refer Chest doc Refer other chirop Refer Chiropedist Refer other advice for weight loss Refer Dietician Refer other iabetolog Refer Dietician Refer other Diebetologist Refer Dietician Refer other diet control - refer Refer Dietician Refer other dietician Refer Dietician Refer other refer to diet Refer Dietician Refer other ipidologist Refer lipidologist Refer other clinic Refer Nurse Refer other nurse Refer Nurse Refer other abg Revascularisation- Revascularisation CABG Revascularisation- Revascularisation ptca Revascularisation- Revascularisation PTCA Revascularisation- Revascularisation stent Revascularisation- Revascularisation

look at Advice table risk with NZ (if apprp statin) Advice table Sheff Table (statin) Advice table check charts (statin) Advice table assess (Framingham) Risk calculator - risk Risk calculator - check risk profile Risk calculator - risk calc Risk calculator - work out Fram Risk Risk calculator - DM Diabetes - diabetes control Diabetes PSV lic consideration Think aloud - ANAEMIA - WHY? Think aloud - BP control Think aloud - cardiac rehab Think aloud - CONTACT WITH ASBESTOS Think aloud - GI? Think aloud - Gastro-intestinal? H pylori Think aloud - Peptic ulcer? hibernation Think aloud - MINING? Think aloud - must take the meds Think aloud - NO GI or C disease Think aloud - no refer Think aloud - q diag Think aloud - rehab Think aloud - sleep at night? sob at night?ESR testRea Think aloud - stress Think aloud - anxiety Think aloud - support Think aloud -

admit Urgent patient - urgent Urgent patient - quickly Urgent patient - urg Urgent patient - Urgent Urgent patient - URGENT CABG Urgent patient - meno Women’s issue - HRT Women's issue - heavy men cycle? Women's issue - pre-m Women's issue - PREMEN? Women's issue -

Medical decision making and coronary heart disease

I Participant Code _________ Date of Interview _________ Interviewer _________

Cardiologist nterview (CI1)

________________________

Medical Decision Making in Cardiology: Post task interview

During the computer task we varied a number of features of each case. This was to see how it

influenced your selection and use of information in your decision making. There are three

aims for this interview. Firstly, we want your explicit opinion as to how each piece of

information influenced your decision making. Secondly, we want to know how your decision

making on this computer task relates to your experience in the real world. Thirdly, we want to

explore your understanding, as an expert in cardiology, of the influence of clinical and non-

clinical information on real-world decision making for these types of cases. The first part of

this interview is well structured and involves presenting you with graphical information to see

how different information influenced your behaviour. The second and third parts are semi-

structured. We have some specific questions but also want you to talk freely around and

beyond these.

SECTION A: How the information influenced your decision making and test

ordering on the task.

A number of different judgments and decisions were made during the task. Here we want to

ask to ask you about six possible decisions or judgments that may have been made for each of

the patients you saw: ordering an angiogram, ordering an exercise test, ordering a cholesterol

test, referring for revascularisation, prescribing a statin and making a judgment about the

patients risk of a coronary event within 10 years. Here we want your opinion as to how the

information available influenced each type of decision across all the cases on the computer

task. We will do this by asking you specific questions about the information available and the

types of patients.

Firstly, for each type of decision, we want you to list the information on the task that

influenced that decision. Then we will show you a list of all the pieces of information that

were available. Again we want you to indicate which pieces of information affected each type

of decision. Thirdly, we want you to try to indicate how that information influenced that

decision. This will be done using some graphs. For each of these factors we want you to

indicate the effects of this variable across all cases that you saw on the computer task, other

factors remaining equal. If the effect of different levels of this factor depends on other pieces

of information then we would like you illustrate or describe this. Finally, we’re also interested

in whether the influence of one piece of information depends on the value of others – for

example smoking may have only influenced your decision making if the person was also a

drinker.

It's important to focus on how you were making judgments and decisions during the computer

task. You will have a chance later to indicate if this was different from your decision making

in real life. First we are interested in the effects of each variable, or type of information across

all the cases on the computer task, other factors remaining equal. If the effect of different

levels of this factor depends on other pieces of information then we would like you to

illustrate or describe this. We are aware that information may influence more than one

judgment or decision, this is fine and we should pick that up.

Decision: Refer for a coronary angiogram.

Cued Recall

Free Recall

Information

Sex Age Ethnicity 12 lead ECG Thallium scan Onset with physical activity Onset without physical activity Character of pain (or discomfort) Duration of pain (or discomfort) Weight loss Current medication Level of physical activity Diet Alcohol consumption Smoking Current blood pressure Exercise tolerance test Family history of coronary disease Body mass index Cholesterol level Previous blood pressure reading Allergies Job Home situation Toothache Fever Headaches Sore throat Cough Number of previous illnesses recorded Guidelines Patient’s risk of CHD

Decision: Refer for an exercise tolerance test Graph

Cued Recall

Free Recall

Information

Sex Age Ethnicity Coronary angiogram 12 lead ECG Thallium scan Onset with physical activity Onset without physical activity Character of pain (or discomfort) Duration of pain (or discomfort) Weight loss Current medication Level of physical activity Diet Alcohol consumption Smoking Current blood pressure Family history of coronary disease Body mass index Cholesterol level Previous blood pressure reading Allergies Job Home situation Toothache Fever Headaches Sore throat Cough Number of previous illnesses recorded Guidelines Patient’s risk of CHD

Decision: Order a cholesterol test

Cued Recall

Free Recall

Information

Sex Age Ethnicity 12 lead ECG Coronary angiogram Thallium scan Onset with physical activity Onset without physical activity Character of pain (or discomfort) Duration of pain (or discomfort) Weight loss Current medication Level of physical activity Diet Alcohol consumption Smoking Current blood pressure Exercise tolerance test Family history of coronary disease Body mass index Cholesterol level Previous blood pressure reading Allergies Job Home situation Toothache Fever Headaches Sore throat Cough Number of previous illnesses recorded Guidelines Patient’s risk of CHD

Decision: Prescribe a statin

Cued Recall

Free Recall

Information

Sex Age Ethnicity Coronary angiogram 12 lead ECG Thallium scan Onset with physical activity Onset without physical activity Character of pain (or discomfort) Duration of pain (or discomfort) Weight loss Current medication Level of physical activity Diet Alcohol consumption Smoking Current blood pressure Exercise tolerance test Family history of coronary disease Body mass index Cholesterol level Previous blood pressure reading Allergies Job Home situation Toothache Fever Headaches Sore throat Cough Number of previous illnesses recorded Guidelines

Patient’s risk of CHD

Decision: Refer for revascularisation (CABG or PTCA)

Cued Recall

Free Recall

Information

Sex Age Ethnicity 12 lead ECG Coronary angiogram Thallium scan Onset with physical activity Onset without physical activity Character of pain (or discomfort) Duration of pain (or discomfort) Weight loss Current medication Level of physical activity Diet Alcohol consumption Smoking Current blood pressure Exercise tolerance test Family history of coronary disease Body mass index Cholesterol level Previous blood pressure reading Allergies Job Home situation Toothache Fever Headaches Sore throat Cough Number of previous illnesses recorded Guidelines Patient’s risk of CHD

Judgment: Patients risk of a coronary event within 10 years.

Cued Recall

Free Recall

Information

Sex Age Ethnicity Coronary angiogram 12 lead ECG Thallium scan Onset with physical activity Onset without physical activity Character of pain (or discomfort) Duration of pain (or discomfort) Weight loss Current medication Level of physical activity Diet Alcohol consumption Smoking Current blood pressure Exercise tolerance test Family history of coronary disease Body mass index Cholesterol level Previous blood pressure reading Allergies Job Home situation Toothache Fever Headaches Sore throat Cough Number of previous illnesses recorded Guidelines

SECTION B: The relationship between decision making on the task and in the real world.

• At the beginning of the computer based task we instructed you to only select the most

important information for each case. In real life cases what (if any) additional information would you seek.

• In what way did the cases you see differ from those that you see in real life?

• We have asked you specifically about the information influencing your decision

making on the task. How does this information influence your decision making in real life? Is other information influential?

SECTION C: The influence of clinical and non-clinical information on real-world decision-making for these type of cases. The project is designed to examine the processes underlying decision making for patients with suspected coronary disease. In this study we examine the effects of clinical and non-clinical features of the patient on decision-making. We will also examine the influence of situational factors on the general patterns of decision-making across doctors. By situational factors we mean things like equipment, staff and time resources, budget, hospital policy, doctors age, sex, religion etc. Now we’d like to explore your views on the influence of situational factors in decision making for patients with suspected coronary problems. How, if at all do you think any of the following situational factors affect decision-making or interact with patient factors to affect decision-making. In particular, we are interested in whether you think these situational factors affect the treatment of different types of patient differently. By different types of patient we mean patients of, for example, different age, sex, ethnicity, and lifestyle. Feel free to use examples from your own experience or to talk in general terms.

Situational factors:

Equipment resources

Staff resources

Budget (financial resources)

Time resources

Hospital policy

Doctors’ age, sex, ethnic origin, religion etc.

In ) Participant Code _________ Date of Interview _________ Interviewer _________

Elderly Care terview (ECI1

________________________

explore your understanding, as an expert in care of the elderly, of the influence of clinical and

non-clinical information on real-world decision making for these types of cases. The first part

of this interview is well structured and involves presenting you with graphical information to

see how different information influenced your behaviour. The second and third parts are semi-

beyond these.

SECTION A: How the information influenced your decision making and test ordering

on the task.

ask to ask you about five possible decisions or judgments that may have been made for each

of the patients you saw: a referral to cardiology, ordering an exercise test, ordering a

cholesterol test, prescribing a statin and making a judgment about the patients risk of a

coronary event within 10 years. Here we want your opinion as to how the information

available influenced each type of decision across all the cases on the computer task. We will

do this by asking you specific questions about the information available and the types of

patients.

drinker.

Decision: Refer to a cardiologist.

Cued Recall

Free Recall

Information

Sex Age Ethnicity 12 lead ECG Thallium scan Onset with physical activity Onset without physical activity Character of chest chest pain (or

discomfort) Duration of chest chest pain (or discomfort) Weight loss Current medication Level of physical activity Diet Alcohol consumption Smoking Current blood pressure Exercise tolerance test Family history of coronary disease Body mass index Cholesterol level Previous blood pressure reading Allergies Job Home situation Toothache Fever Headaches Sore throat Cough Number of previous illnesses recorded Guidelines Patient’s risk of CHD

Cued Recall

Free Recall

Information

Decision: Refer for an exercise tolerance test Graph

Cued Recall

Free Recall

Information

discomfort) Duration of chest chest pain (or discomfort) Weight loss Current medication Level of physical activity Diet Alcohol consumption Smoking Current blood pressure Family history of coronary disease Body mass index Cholesterol level Previous blood pressure reading Allergies Job Home situation Toothache Fever Headaches Sore throat Cough Number of previous illnesses recorded Guidelines Patient’s risk of CHD

Cued Recall

Free Recall

Information

Cued Recall

Free Recall

Information

discomfort) Duration of chest chest pain (or discomfort) Weight loss Current medication Level of physical activity Diet Alcohol consumption Smoking Current blood pressure Exercise tolerance test Family history of coronary disease Body mass index Cholesterol level Previous blood pressure reading Allergies Job Home situation Toothache Fever Headaches Sore throat Cough Number of previous illnesses recorded Guidelines

SECTION C: The influence of clinical and non-clinical information on real-world decision-making for these type of cases. The project is designed to examine the processes underlying decision making for patients with suspected coronary disease. In this study we examine the effects of clinical and non-clinical features of the patient on decision-making. We will also examine the influence of situational factors on the general patterns of decision-making across doctors. By situational factors we mean things like equipment, staff and time resources, budget, hospital policy, doctors age, sex, religion etc. Now we’d like to explore your views on the influence of situational factors in decision making for patients with suspected coronary problems. How, if at all do you think any of the following situational factors affect decision-making or interact with patient factors to affect decision-making. In particular, we are interested in whether you think these situational factors affect the treatment of different types of patient differently. By different types of patient we mean patients of, for example, different age, sex, ethnicity, and lifestyle. Feel free to use examples from your own experience or to talk in general terms.

Equipment resources

Staff resources

Time resources

Hospital policy

Participant Code ____ Date of Interview ____ Interviewer ____

General Practitioner Interview (GPI1)

_____________________________

explore your understanding, as an expert in general practice, of the influence of clinical and

non-clinical information on real-world decision making for these types of cases. The first part

of this interview is well structured and involves presenting you with graphical information to

see how different information influenced your behaviour. The second and third parts are semi-

beyond these.

SECTION A: How the information influenced your decision making and test ordering

on the task.

ask to ask you about five possible decisions or judgments that may have been made for each

of the patients you saw: a referral to cardiology, ordering an exercise test, ordering a

cholesterol test, prescribing a statin and making a judgment about the patient’s risk of a

coronary event within 10 years. Here we want your opinion as to how the information

available influenced each type of decision across all the cases on the computer task. We will

do this by asking you specific questions about the information available and the types of

patients.

drinker.

Decision: Refer to a cardiologist

Cued Recall

Free Recall

Information

Sex Age Ethnicity 12 lead ECG Thallium scan Onset with physical activity Onset without physical activity Character of chest pain (or discomfort) Duration of chest pain (or discomfort) Weight loss Current medication Level of physical activity Diet Alcohol consumption Smoking Current blood pressure Exercise tolerance test Family history of coronary disease Body mass index Cholesterol level Previous blood pressure reading Allergies Job Home situation Toothache Fever Headaches Sore throat History of Cough Number of previous illnesses recorded Guidelines Patient’s risk of CHD

Cued Recall

Free Recall

Information

Decision: Refer for an exercise tolerance test

Cued Recall

Free Recall

Information

Sex Age Ethnicity 12 lead ECG Thallium scan Onset with physical activity Onset without physical activity Character of chest pain (or discomfort) Duration of chest pain (or discomfort) Weight loss Current medication Level of physical activity Diet Alcohol consumption Smoking Current blood pressure Family history of coronary disease Body mass index Cholesterol level Previous blood pressure reading Allergies Job Home situation Toothache Fever Headaches Sore throat History of Cough Number of previous illnesses recorded Guidelines Patient’s risk of CHD

Cued Recall

Free Recall

Information

Cued Recall

Free Recall

Information

Sex Age Ethnicity 12 lead ECG Thallium scan Onset with physical activity Onset without physical activity Character of chest pain (or discomfort) Duration of chest pain (or discomfort) Weight loss Current medication Level of physical activity Diet Alcohol consumption Smoking Current blood pressure Exercise tolerance test Family history of coronary disease Body mass index Cholesterol level Previous blood pressure reading Allergies Job Home situation Toothache Fever Headaches Sore throat History of Cough Number of previous illnesses recorded Guidelines

SECTION C: The influence of clinical and non-clinical information on real-world decision-making for these types of cases. The project is designed to examine the processes underlying decision making for patients with suspected coronary disease. In this study we examine the effects of clinical and non-clinical features of the patient on decision-making. We will also examine the influence of situational factors on the general patterns of decision-making across doctors. By situational factors we mean things like equipment, staff and time resources, budget, hospital policy, doctors age, sex, religion etc. Now we’d like to explore your views on the influence of situational factors in decision making for patients with suspected coronary problems. How, if at all do you think any of the following situational factors affect decision-making or interact with patient factors to affect decision-making. In particular, we are interested in whether you think these situational factors affect the treatment of different types of patient differently. By different types of patient we mean patients of, for example, different age, sex, ethnicity, and lifestyle. Feel free to use examples from your own experience or to talk in general terms.

Equipment resources

Staff resources

Time resources

Hospital policy

Risk by toothache

No, no toothache Yes, I've had some toothache

t with

Risk by thallium

A There is mild inferolateral inducible ischaemia suggesting a low likelihood of future coronary events.

B There is inducible ischaemia of the anterior wall, apex, inferior wall and septurn which is mild to moderateseverity. The scan suggests a moderate risk of future coronary events.

C There is inferolateral ischaemia that is moderate to severe. The scan suggests a moderate to high risk of coronary events.

D Homegenous mycardial perfusion during Adenosine vasodilation. There is therefore no significant coronaryobstruction and the risk of future coronary events is low.

t with

Risk by sore throat

Yes, I've had a sore throat

t with

No, no sore throat

Risk by smoking

Non-smoker Smoked for years Used to smoke Packet-a-day

t with

Risk by sex

Male Female

t with

Risk by primary trigger of the chest discomfort

A If I walk for a couple of hundred yards or if I exert myself too quickly

B Just after I start any physical activity

C If I push myself really hard or if I exert myself for a long period of time

D Without doing any physical activity

t with

Risk by Number of previous illnesses recorded

None Four

t with

Risk by previous blood pressure reading

t with

165/100 155/95

125/85 140/95

Risk by level of physical activity

Inactivelifestyle lifestyle lifestyle

Moderately active Highly active

t with

Risk by onset without physical activity

t with

Sometimes after

angry or frustrated I've eatenIt comes on withou doing

Sometimes, when I'm in the cold

anything

Sometimes, when I'm

Risk by onset with physical activity

t with

Risk by home situation

t with

Lives with relatives

Lives alone

Lives with partner/spouse

Risk by history of headaches

Yes, I've had headaches

t with

No, no headaches

Risk by history of fever

No, no fever Yes, I've had a fever

t with

Risk by family history

heart diseaseFamily history of coronary

t with

None recorded

Risk by exercise tolerance test

A Normal HR and BP response. Patient is asymptomatic and there are no significant ST changes.

B Patient is symptomatic; with no ST changes.

C Exercise test shows some ST depression.

D Exercise tests shows marked horizontal downsloping ST depression in several leads.

E Exercise test shows downsloping ST depression in anterior leads.

t with

BA C D

Risk by ethnicity

born in India

born in Pakistan

t with

born in EnglandWhite/

White/born in Wales

White/born in Scotland

Black/born in England

Black/born in Africa

Black/born in Caribbean

Asian/

Asian/Asian/born in Bangladesh

Risk by duration of chest pain (or discomfort)

A few minutes About 1/2 hour

Few seconds About 10 minutes

t with

Risk by diet

Balanced diet High fat diet

t with

Risk by diabetes

Type 1 diabetic Non-diabetic Type II diabetic

t with

Risk by current medications

A Aspirin (or clopidigrol), isosorbide dinitrate, atenolol

B Isosorbide dinitrate, atenolol and nifedipine

C Aspirin (or clopidigrol) and isosorbide dinitrate

D Aspirin (or clopidigrol), isosorbide dinitrate and nifedipine

E Isosorbide dinitrate

BA C D

t with

Risk by current blood pressure

165/100 155/95

125/85 140/95

t with

Risk by history of cough

Yes, I've had a cough

t with

No, no cough

Risk by cholesterol level

A Cholesterol 4.9 [2.3-5.2] C Cholesterol 6.5 [2.3-5.2] E Cholesterol 8.7 [2.3-5.2]Triglyceride 0.6 [0.4-1.8] Triglyceride 3.0 [0.4-1.8] Triglyceride 2.8 [0.4-1.8]HDL 1.2 [0.9-1.4] HDL 0.7 [0.9-1.4] HDL 1.9 [0.9-1.4]LDL 2.6 [0-3.5] LDL 2.9 [0-3.5] LDL 5.5 [0-3.5]

B Cholesterol 3.7 [2.3-5.2] D Cholesterol 7.9 [2.3-5.2]Triglyceride 1.3 [0.4-1.8] Triglyceride 1.7 [0.4-1.8]HDL 1.5 [0.9-1.4] HDL 0.6 [0.9-1.4]LDL 1.6 [0-3.5] LDL 6.5 [0-3.5]

[All in mmol/L]

BA C D

t with

Risk by character pain (or discomfort)

A heavy feeling

t with

Short of breath A burning feeling An aching feeling A tight feeling

Risk by character of chest discomfort

t with

An aching feeling A tight feeling

Short of breath A burning feeling

Risk by body mass index

<20 20-25 26-30 >30

t with

Overweight Obese

Underweight Normal

Risk by angiogram

A Normal LV function. Normal coronaries.

B Good LV function. LMS - very tight lesion. LAD - multiple tight lesions in proximal vessel with good calibre distally. Circumflex - tight proximal lesion with large distal vessel with only mild irregularity. Crossfills RCA retrogradely. RCA - occluded proximally.

C Good LV function. LMS: LAD has severe midcourse discrete stenosis. CX: normal. RCA: normal.

D Separate origin for LAD and circumflex. LAD - minor disease only. Circumflex - mild/moderate lesion in midcourse. RCA large vessel with no

E Poor overall LV function with marked apical akinesis. LMS - very short. LAD - tight extremely proximal lesion and then tight complexmidvessel stenosis. Large diagonal with mild early disease. Circumflex - severely diseased proximally in large vessel with earlymid/moderate disease.

F Good LV function with mild hypokinesis. LMS - large normal. LAD multiple tight proximal lesions which also involves the main diagonalsDistal portion of RCA fills retrogradely. Circumflex - small vessel, large OM1 with a 60% proximal lesion. RCA - large vessel with tightmidcourse disease and then further disease leading to occlusion in distal vessel.

significant lesions.

t with

BA C D

Risk by allergies

Allergic to aspirin No allergies

t with

Risk by alcohol consumption

A Teetotal

B Drinks moderately: <15 units [male]

C Drinks moderately: <10 units [female]

D Drinks heavily: 20-30 units [male]

E Drinks heavily 14-20 units [female]

F Drinks very heavily: >30 units [male]

t with

G Drinks very heavily >20 units [female]

Risk by age

t with

66+46-55 56-65

Risk by 12 lead ECG

A Normal SR, normal QRS axis. Shows non-specific ST-T changes

B Normal SR, normal QRS axis. Shows ST depression in all anterior leads

C Normal SR, normal QRS axis. There is symmetrical T wave inversion in the anterior septal leads

D Normal SR, normal QRS axis. Patient is asympomatic

t with

Angiogram by ethnicity

[Definitely will not]

[Definitely will]

Asian/

Asian/Asian/born in Bangladeshborn in England

White/

White/born in Wales

born in India

born in Pakistan

Prescribing by weight history

No weight loss

[Definitely will]

Weight loss

Prescribing by toothache

[Definitely will]

no, no toothache Yes, I've had some toothache

Prescribing by thallium

A There is mild inferolateral inducible ischaemia suggesting a low likelihood of future coronary events.B There is inducible ischaemia of the anterior wall, apex, inferior wall and septurn which is mild to moderate

severity. The scan suggests a moderate risk of future coronary events.C There is inferolateral ischaemia that is moderate to severe. The scan suggests a moderate to high risk of

coronary events.D Homegenous mycardial perfusion during Adenosine vasodilation. There is therefore no significant coronary

obstruction and the risk of future coronary events is low.

[Definitely will]

A B C D

Prescribing by sore throat

no, no sore throat Yes, I've had a sore throat

[Definitely will]

Prescribing by smoking

Used to smoke

Non-smoker Smoked for years Packet-a-day

[Definitely will]

Prescribing by sex

[Definitely will]

Female

Prescribing by previous blood pressure

165/100

125/85 140/95 155/95

[Definitely will]

Prescribing by onset without physical activity

[Definitely will]

I've eaten[Definitely will not] It comes on Sometimes, when Sometimes, when I'm Sometimes after

anythingwithout doing I'm in the cold angry or frustrated

Prescribing by onset with physical activity

[Definitely will]

Prescribing by number of previous illnesses recorded

[Definitely will]

None Four

Prescribing by level of physical activity

[Definitely will]

active lifestyle lifestyle lifestyle

Inactive Moderately Highly active

Prescribing by home situation

[Definitely will]

Lives alone

spouse[Definitely will not] Lives with partner/

Prescribing by headhaches

[Definitely will]

no, no headaches Yes, I've had some headaches

Prescribing by fever

[Definitely will]

Prescribing by family history

[Definitely will]

coronary diseaseNone recorded

Family history of[Definitely will not]

Prescribing by exercise tolerance test

A B C E

[Definitely will]

Prescribing by ethnicity

born in India

born in Pakistan

Asian/

[Definitely will]

White/born in Wales

Prescribing by duration of pain (or discomfort)

Few seconds A few minutes About 10 minutes About 1/2 hour

[Definitely will]

Prescribing by diet

High fat dietBalanced diet

[Definitely will]

Prescribing by current medications

BA C D

Prescribing by current blood pressure

155/95

[Definitely will]

125/85 140/95 165/100

Prescribing by cough

[Definitely will]

No, no cough Yes, I've had a cough

Prescribing by cholesterol level

A Cholesterol 4.9 [2.3-5.2] C Cholesterol 6.5 [2.3-5.2] E Cholesterol 8.7 [2.3-5.2]Triglyceride 0.6 [0.4-1.8] Triglyceride 3 [0.4-1.8] Triglyceride 2.8 [0.4-1.8]HDL 1.2 [0.9-1.4] HDL 0.7 [0.9-1.4] HDL 1.9 [0.9-1.4]LDL 2.6 [0-3.5] LDL 2.9 [0-3.5] LDL 5.5 [0-3.5]

[All in mmol/L]

[Definitely will]

A C D EB

Prescribing by character of pain (or discomfort)

A heavy feeling

[Definitely will not] A burning feelingShort of breath An aching feeling A tight feeling

[Definitely will]

Prescribing by body mass index

<20Normal

Overweight[Definitely will not] Underweight

[Definitely will]

20-25 26-30Obese

Prescribing by angiogram

B Good LV function. LMS - very tight lesion. LAD - multiple tight lesions in proximal vessel with good calibre distally. Circumflex - tight proxilesion with large distal vessel with only mild irregularity. Crossfills RCA retrogradely. RCA - occluded proximally.

D Separate origin for LAD and circumflex. LAD - minor disease only. Circumflex - mild/moderate lesion in midcourse. RCA large vessel with

[Definitely will]

BA C D[Definitely will not]

Prescribing by allergies

[Definitely will]

Prescribing by alcohol consumption

A Teetotal

DA C E

[Definitely will]

Prescribing by age

[Definitely will]

66+46-55

Prescribing by 12 lead ECG

D[Definitely will not]

[Definitely will]

Exercise test by age

[Definitely will]

66+46-55 56-65

Exercise tolerance test by weight history

No weight loss

[Definitely will]

Weight loss

Exercise tolerance test by toothache

[Definitely will]

Exercise tolerance test by thallium

[Definitely will]

A B C D

Exercise tolerance test by sore throat

[Definitely will]

Exercise tolerance test by smoking

Used to smoke

[Definitely will]

Exercise tolerance test by sex

[Definitely will]

Female

Exercise tolerance test by previous blood pressure

165/100

125/85 140/95 155/95

[Definitely will]

Exercise tolerance test by onset without physical activity

[Definitely will]

Exercise tolerance test by onset with physical activity

[Definitely will]

Exercise tolerance test by number of previous illnesses recorded

[Definitely will]

None Four Eight

Exercise tolerance test by level of physical activity

[Definitely will]

Exercise tolerance test by home situation

[Definitely will]

Lives alone

Exercise tolerance test by headhaches

[Definitely will]

Exercise tolerance test by fever

[Definitely will]

Exercise tolerance test by family history

[Definitely will]

Exercise tolerance test by ethnicity

born in India

born in Pakistan

Asian/

[Definitely will]

White/born in Wales

Exercise tolerance test by duration of pain (or discomfort)

[Definitely will]

Exercise tolerance test by diet

[Definitely will]

Exercise tolerance test by current medications

BA C D

Exercise tolerance test by current blood pressure

155/95

[Definitely will]

125/85 140/95 165/100

Exercise tolerance test by cough

[Definitely will]

Exercise tolerance test by cholesterol level

[All in mmol/L]

[Definitely will]

A C D EB

Exercise tolerance test by character of pain (or discomfort)

A heavy feeling

[Definitely will]

Exercise tolerance test by body mass index

<20Normal

[Definitely will]

20-25 26-30Obese

Exercise tolerance test by angiogram

B Good LV function. LMS - very tight lesion. LAD - multiple tight lesions in proximal vessel with good calibre distally. Circumflex - tight proxilesion with large distal vessel with only mild irregularity. Crossfills RCA retrogradely. RCA - occluded proximally.

D Separate origin for LAD and circumflex. LAD - minor disease only. Circumflex - mild/moderate lesion in midcourse. RCA large vessel with

[Definitely will]

BA C D[Definitely will not]

Exercise tolerance test by allergies

[Definitely will]

Exercise tolerance test by alcohol consumption

A Teetotal

[Definitely will]

DA C E G

Exercise tolerance test by 12 lead ECG

[Definitely will]

Cholesterol by weight history

Overweight26-30

Obese>30

Underweight<20

Normal20-25

[Definitely will]

Cholesterol by toothache

[Definitely will]

Cholesterol by thallium

[Definitely will]

A B C D

Cholesterol by sore throat

[Definitely will]

Cholesterol by smoking

Used to smoke

[Definitely will]

Cholesterol by sex

[Definitely will]

Male Female

Cholesterol by previous blood pressure

[Definitely will]

125/85 140/95 165/100 155/95

Cholesterol by onset without physical activity

[Definitely will]

Cholesterol by onset with physical activity

[Definitely will]

Cholesterol by number of previous illnesses recorded

[Definitely will]

None Four Eight

Cholesterol by home situation

[Definitely will]

Lives alone

Cholesterol by headhaches

[Definitely will]

Cholesterol by fever

[Definitely will]

Cholesterol by family history

[Definitely will]

Cholesterol by exercise tolerance test

A B C E

[Definitely will]

Cholesterol by ethnicity

born in India

born in Pakistan

Asian/

[Definitely will]

White/born in Wales

Cholesterol by level of physical activity

[Definitely will]

Cholesterol by current blood pressure

125/85 140/95 165/100 155/95

[Definitely will]

Cholesterol by cough

Yes, I've had a coughNo, no cough

[Definitely will]

Cholesterol by character of pain (or discomfort)

A tight feeling A heavy feelingShort of breath A burning feeling An aching feeling

[Definitely will]

Cholesterol by body mass index

<20Normal

[Definitely will]

20-25 26-30Obese

Cholesterol by allergies

[Definitely will]

Cholesterol by alcohol consumption

A Teetotal

B D FA C E G

[Definitely will]

Cholesterol by age

[Definitely will]

66+46-55 56-65

Cholesterol by 12 lead ECG

[Definitely will]

Cholesterol by diet

[Definitely will]

Cholesterol by duration of pain (or discomfort)

[Definitely will]

Cardiology referral by weight history

No weight loss

[Definitely will]

Weight loss

Cardiology referral by toothache

[Definitely will]

Cardiology referral by thallium

[Definitely will]

A B C D

Cardiology referral by sore throat

[Definitely will]

Cardiology referral by smoking

Used to smoke

[Definitely will]

Cardiology referral by sex

[Definitely will]

Female

Cardiology referral by previous blood pressure

165/100

125/85 140/95 155/95

[Definitely will]

Cardiology referral by onset without physical activity

[Definitely will]

Cardiology referral by onset with physical activity

[Definitely will]

Cardiology referral by number of previous illnesses recorded

[Definitely will]

None Four Eight

Cardiology referral by level of physical activity

[Definitely will]

Cardiology referral by home situation

[Definitely will]

Lives alone

Cardiology referral by headhaches

[Definitely will]

Cardiology referral by fever

[Definitely will]

Cardiology referral by family history

[Definitely will]

Cardiology referral by exercise tolerance test

A B C E

[Definitely will]

Cardiology referral by ethnicity

born in India

born in Pakistan

Asian/

[Definitely will]

White/born in Wales

Cardiology referral by duration of pain (or discomfort)

[Definitely will]

Cardiology referral by diet

[Definitely will]

Cardiology referral by current medications

BA C D

Cardiology referral by current blood pressure

165/100

125/85 140/95 155/95

[Definitely will]

Cardiology referral by cough

[Definitely will]

Cardiology referral by cholesterol level

[All in mmol/L]

[Definitely will]

A C D EB

Cardiology referral by character of pain (or discomfort)

A heavy feeling

[Definitely will]

Cardiology referral by body mass index

<20Normal

[Definitely will]

20-25 26-30Obese

Cardiology referral by allergies

[Definitely will]

Cardiology referral by alcohol consumption

A Teetotal

[Definitely will]

DA C E G

Cardiology referral by age

[Definitely will]

66+46-55

[Definitely will not] 56-65

Cardiology referral by 12 lead ECG

[Definitely will]

Revascularisation by weight history

No weight loss

[Definitely will]

Weight loss

Revascularisation by toothache

[Definitely will]

Revascularisation by thallium

[Definitely will]

A B C D

Revascularisation by sore throat

[Definitely will]

Revascularisation by smoking

Used to smoke

[Definitely will]

Revascularisation by sex

[Definitely will]

Female

Revascularisation by previous blood pressure

165/100

125/85 140/95 155/95

[Definitely will]

Revascularisation by onset without physical activity

[Definitely will]

Revascularisation by onset with physical activity

[Definitely will]

Revascularisation by number of previous illnesses recorded

[Definitely will]

None Four Eight

Revascularisation by level of physical activity

[Definitely will]

Revascularisation by home situation

[Definitely will]

Lives alone

Revascularisation by headhaches

[Definitely will]

Revascularisation by fever

[Definitely will]

Revascularisation by family history

[Definitely will]

Revascularisation by exercise tolerance test

A B C E

[Definitely will]

Revascularisation by ethnicity

born in India

born in Pakistan

Asian/

[Definitely will]

White/born in Wales

Revascularisation by duration of pain (or discomfort)

[Definitely will]

Revascularisation by diet

[Definitely will]

Revascularisation by current medications

BA C D

Revascularisation by current blood pressure

155/95

[Definitely will]

125/85 140/95 165/100

Revascularisation by cough

[Definitely will]

Revascularisation by cholesterol level

[All in mmol/L]

[Definitely will]

A C D EB

Revascularisation by character of pain (or discomfort)

A heavy feeling

[Definitely will]

Revascularisation by body mass index

<20Normal

[Definitely will]

20-25 26-30Obese

Revascularisation by allergies

[Definitely will]

Revascularisation alcohol consumption

A Teetotal

[Definitely will]

DA C E G

Revascularisation by age

[Definitely will]

66+46-55

Revascularisation by 12 lead ECG

[Definitely will]

Cholesterol by body mass index

26-30Obese

>30Overweight[Definitely will not] Underweight

[Definitely will]

<20Normal

Angiogram by age

[Definitely will]

66+46-55

Angiogram by weight history

No weight loss

Weight loss

[Definitely will]

Angiogram by diet

No, no toothache

Yes, I've had some toothache

[Definitely will]

Angiogram by thallium

A B C D

[Definitely will]

Angiogram by sore throat

[Definitely will]

Angiogram by smoking

Packet-a-day

[Definitely will]

Non-smoker Smoked for years Used to smoke

Angiogram by sex

Female

[Definitely will]

Angiogram by previous blood pressure

155/95

[Definitely will]

125/85 140/95 165/100

Angiogram by onset without physical activity

anythingwithout doing I'm in the cold angry or frustrated I've eaten

[Definitely will not] It comes on Sometimes, when Sometimes, when I'm Sometimes after

[Definitely will]

Angiogram by onset with physical activity

[Definitely will]

Angiogram by number of previous illnesses recorded

None Four Eight

[Definitely will]

Angiogram by level of physical activity

[Definitely will]

Angiogram by home situation

spouse[Definitely will not]

[Definitely will]

Lives alone

Lives with partner/

Angiogram by headhaches

[Definitely will]

Angiogram by fever

[Definitely will]

No, no fever

Yes, I've had a fever

Angiogram by family history

[Definitely will]

Family history of

Angiogram by exercise tolerance test

[Definitely will]

A B C D

Angiogram by duration of pain (or discomfort)

[Definitely will]

Angiogram by diet

[Definitely will]

Angiogram by current medications

EA B C D

[Definitely will]

Angiogram by current blood pressure

165/100

125/85 140/95 155/95

[Definitely will]

Angiogram by cough

[Definitely will]

Angiogram by cholesterol level

[All in mmol/L]

A C D EB

[Definitely will]

Angiogram by character of pain (or discomfort)

A heavy feeling

[Definitely will]

Angiogram by body mass index

20-25 26-30Obese

[Definitely will]

Overweight[Definitely will not] Underweight<20

Normal

Angiogram by allergies

[Definitely will]

Angiogram alcohol consumption

A Teetotal

A C E GB

[Definitely will]

Angiogram by 12 lead ECG

B C D[Definitely will not]

[Definitely will]

Risk by weight history

Weight loss

t with

No weight loss

judgement analysis of the clinical policies of cardiologists, care … · 2003-04-14 ·...

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