How do electronic risk assessment tools affect the communication and understanding of risk and diagnostic uncertainty in the primary care consultation? A systematic review and qualitative synthesis.

Problem

Diagnosis in primary care is complex and challenging. The primary care consultation is fraught with uncertainty: the inputs are variable, imperfect and subjective, and the disease prevalence is low. Good GPs are able to process and communicate risk and accept uncertainty in diagnosis. Communication of these concepts in a way which allows a shared understanding of medicine with a patient, is one of the seminal challenges of primary care.

Diagnostic risk assessment tools are computer based algorithms designed to help GPs to avoid missing a diagnoses, to pick up possible symptoms early and help facilitate shared decision making. However to achieved adequate sensitivity they have a low positive predictive value and some are designed to ‘pop-up’ during a consultation. The impact of these new tools on the consultation dynamic, how it affects clinicians and patients communication of and response to risk requires assessing. This review seeks to understand the extent (or otherwise) of what is known about the impact of electronic risk assessment tools on these aspects of the primary care consultation.

Approach

Searches of MEDLINE, EMBASE, CINAHL and Web of Science were performed. Full search strategy is available at PROSPERO, ID 219446. Three reviewers working independently screened titles and abstracts, and then full text for relevance. Disputes were resolved on discussion between reviewers. Data extraction was via line by line coding to identify direct quotations and researcher comments pertinent to the research question. A thematic synthesis approach is now being used. Descriptive themes have been developed, and analytical themes are in progress.

Findings

5971 unique studies were identified of which 441 underwent full text review. 28 studies were included for data extraction. Electronic risk assessment tools include differential diagnosis suggestion tools, tools which produce a future risk of disease development or recurrence, or refine a risk of current undiagnosed disease. Thematic synthesis is in progress, and will be complete by June 2021.

Consequences

The findings of our review will address important questions regarding the impact of electronic risk tools. This review examines the current qualitative evidence as to how these tools influence the diagnostic process and the discussions or risk and uncertainty which inevitably follow. Such tools are increasing in use, despite limited evidence of benefit. Any potential benefits will need to overcome barriers to implementation and uptake. This review may assist with this challenge.