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Heartbeat: An ecosystem approach to clinical decision making
  1. Catherine M Otto
  1. Correspondence to Professor Catherine M Otto, Division of Cardiology, University of Washington, Seattle, WA 98195, USA; cmotto{at}

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Improving the efficiency of healthcare is essential for reducing healthcare costs. Adherence to evidence-based practice guidelines has the potential to improve health outcomes at lower costs but there are many barriers to consistent implementation of guidelines in clinical practice. Manja and colleagues1 performed a descriptive qualitative study of cardiologists to better understand the major factors influencing clinical decision making including interpersonal interactions, financial incentives and system factors. Major influences in clinical practice ranged from time constraints, patient insurance status, fear of litigation or missing a diagnosis, patient demands, and need to increase personal or practice income (figure 1). Guidelines were less important in decision making and ‘some cardiologists expressed a high level of scepticism regarding guidelines.’ 

Figure 1

(A) Factors influencing decision to discharge a patient with non-cardiac chest pain. (B) Factors influencing decision to perform further testing or admit for observation in a patient with non-cardiac chest pain.

In an editorial, Dabbouseh and Bergl2 point out that in addition to the, …

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