The Association Between Medicolegal and Professional Concerns and Chest Pain Admission Rates

Abstract

Objectives: For patients in whom acute coronary syndrome (ACS) is a concern, disposition decisions are complex and multifactorial and have traditionally been a source of considerable variation. An important factor in disposition decisions for these patients may be physician-perceived medicolegal risk and related professional concerns. The study aim was to determine, at the point of care, how much less frequently physicians report that they would admit possible ACS patients if there was either zero or a defined medicolegal risk.Methods: This was a point-of-care emergency physician survey. Research assistants approached physicians at or immediately following the moment of disposition decisions for patients who were being admitted for ACS. The primary outcome measures were the proportion of physicians reporting that patients would not have been admitted if medicolegal issues were of no concern and the proportion of physicians reporting that patients would not have been admitted if there was an "acceptable miss rate" of 1% to 2% for ACS patients.Results: During the 3-month study period, 576 patients were admitted to an inpatient unit or to the ED observation protocol. Physicians were approached in 271 cases, and 259 surveys were completed. When presented with hypothetical zero medicolegal risk, physicians answered that they would not have admitted the patients in 30% of cases. With a hypothetical 1% to 2% acceptable miss rate, physicians indicated that they would not have admitted the patients in 29% of the cases.Conclusions: ED medicolegal and professional concerns may substantially increase admissions for possible ACS. An acceptable miss rate or a zero medicolegal risk environment could potentially lead to a major reduction in admissions that physicians feel to be clinically unnecessary.ACADEMIC EMERGENCY MEDICINE 2015;22:883-886 © 2015 by the Society for Academic Emergency Medicine A cute coronary syndrome (ACS) is a common concern in emergency department (ED) settings and a common reason for extended evaluation using accelerated diagnostic protocols in observation units or inpatient hospital settings. For patients in whom ACS is a concern, disposition decisions are complex and multifactorial and have traditionally been a source of considerable variation.1,2 An important factor in disposition decisions for these patients may be physician-perceived medicolegal risk and related professional concerns. [3][4][5] Previous work has been done examining the concept of a test threshold, or "acceptable miss rate," for ACS. [6][7][8] However, such thresholds have not been routinely integrated into disposition decision-making and their possible effect on physician decision-making has, to our knowledge, not been previously reported.We aimed to determine, at the point of care, how often perceived medicolegal concerns affect physician

Overcrowding in the Emergency Department and Patient Safety

“…As medical imaging has improved and expanded, ED workups have grown to utilize more advanced imaging, increasing ED length of stay (LOS) for patients [13]. Furthermore, physicians' medicolegal concerns and fear of lawsuit increase their diagnostic testing as well as impacts their admission decisions, contributing to resource/demand mismatch [14].…”

Automated Retrospective Calculation of the EDACS and HEART Scores in a Multicenter Prospective Cohort of Emergency Department Chest Pain Patients

“…Prospective agreement data for the EDACS are limited to the initial validation study among a subset of 60 patients. 5 The authors reported ICCs of 0.87 and 0.80 for the dichotomous EDACS-ADP classification Coronary artery disease (%) 15 (14)(15) Coronary revascularization (%) 12 (11)(12)(13) Myocardial infarction (%) 9 (9-10)…”

“…Smoker in past 90 days (%) 12 (12)(13) Family history of premature coronary disease (%) 20 (19)(20)(21) Body mass index ≥ 30 kg/m 2 (%) 37 (37-38) Symptoms Diaphoresis (%) 11 (10)(11)(12) Radiating pain (%) 25 (24)(25)(26) Pain worse with palpation (%) 17 (16)(17)(18) Pain worse with inspiration (%) 16 (15)(16) Exertional symptoms (%) 15 (14)(15) Sharp or stabbing pain (%) 27 (26)(27) Nausea or vomiting (%) 15 (14)(15)(16) Crescendo and continuous EDACS score, respectively, corresponding to a kappa of 0.73 and an ICC of 0.87 in our study. Taken together, these findings support the validity of the automated retrospective risk determination approach presented herein.…”

“…[7][8][9][10] The use of these risk scores may allow for direct discharge of patients with chest pain from the ED without further planned cardiac testing, an approach that is safe, medicolegally acceptable to clinicians, and cost-effective. [11][12][13][14] Extraction and processing of unstructured free text from the electronic health record (EHR) offers an avenue by which these risk scores could be efficiently determined retrospectively and at scale. Using this free-text extraction approach, we previously devised a method of retrospectively calculating EDACS and HEART scores for ED chest pain patients by extracting both structured and unstructured data from the databases of a large integrated health delivery system EHR.…”

Emergency Physician Knowledge, Attitudes, and Behavior Regarding ACEP's Choosing Wisely Recommendations: A Survey Study

“…Further research on physician risk tolerance is needed to distinguish between fear of missing a serious diagnosis and fear of malpractice. While both contribute to the practice of “defensive medicine,” interventions to assess and modify these risks are different; the former may be improved through education and patient‐centered interventions, while the latter may require changes in professional and legal standards …”