The effect of physician risk tolerance and the presence of an observation unit on decision making for ED patients with chest pain

Pines, Jesse M.; Isserman, Joshua A.; Szyld, Demian; Dean, Anthony J.; McCusker, Christine M.; Hollander, Judd E.

doi:10.1016/j.ajem.2009.03.019

Cited by 127 publications

(78 citation statements)

References 25 publications

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“…16,45,46 As in other studies, physicians who reported taking low levels of personal risk were also more likely to offer extra testing. 38,47,48 Fear of malpractice, however, was not significantly associated with extra testing, consistent with studies that suggest that malpractice concerns either do not influence physician testing practice patterns or play a relatively minor role. [47][48][49][50][51] All of these findings suggest that physicians' cancer screening practices may be associated with risk-aversion of negative medical outcomes (e.g.…”

Section: Resultssupporting

confidence: 82%

Guideline-Inconsistent Breast Cancer Screening for Women over 50: A Vignette-Based Survey

et al. 2013

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Section: Resultssupporting

confidence: 82%

Guideline-Inconsistent Breast Cancer Screening for Women over 50: A Vignette-Based Survey

et al. 2013

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“…While two single-center studies failed to find a relation between stress due to uncertainty, on the one hand, and increased testing in ED patients, on the other, both were underpowered, and thus their findings cannot be considered definitive. 9,55 Others have argued that the role of uncertainty in clinical decision-making affects physician practice variation, and we endorse this view. 56 We believe that the existing desire in modern U.S. health care, to minimize and even eliminate any diagnostic uncertainty, is a primary contributor to our current, resource-intensive approach.…”

Section: Discussionmentioning

confidence: 61%

Emergency Physician Perceptions of Medically Unnecessary Advanced Diagnostic Imaging

Kanzaria

Hoffman

Probst

et al. 2015

Academic Emergency Medicine

170

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Objectives: The objective was to determine emergency physician (EP) perceptions regarding 1) the extent to which they order medically unnecessary advanced diagnostic imaging, 2) factors that contribute to this behavior, and 3) proposed solutions for curbing this practice.Methods: As part of a larger study to engage physicians in the delivery of high-value health care, two multispecialty focus groups were conducted to explore the topic of decision-making around resource utilization, after which qualitative analysis was used to generate survey questions. The survey was extensively pilot-tested and refined for emergency medicine (EM) to focus on advanced diagnostic imaging (i.e., computed tomography [CT] or magnetic resonance imaging [MRI]). The survey was then administered to a national, purposive sample of EPs and EM trainees. Simple descriptive statistics to summarize physician responses are presented.Results: In this study, 478 EPs were approached, of whom 435 (91%) completed the survey; 68% of respondents were board-certified, and roughly half worked in academic emergency departments (EDs). Over 85% of respondents believe too many diagnostic tests are ordered in their own EDs, and 97% said at least some (mean = 22%) of the advanced imaging studies they personally order are medically unnecessary. The main perceived contributors were fear of missing a low-probability diagnosis and fear of litigation. Solutions most commonly felt to be "extremely" or "very" helpful for reducing unnecessary imaging included malpractice reform (79%), increased patient involvement through education (70%) and shared decision-making (56%), feedback to physicians on test-ordering metrics (55%), and improved education of physicians on diagnostic testing (50%). Conclusions:Overordering of advanced imaging may be a systemic problem, as many EPs believe a substantial proportion of such studies, including some they personally order, are medically unnecessary. Respondents cited multiple complex factors with several potential high-yield solutions that must be addressed simultaneously to curb overimaging.ACADEMIC EMERGENCY MEDICINE 2015;22:390-398

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“…[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.…”

Section: Introductionmentioning

confidence: 99%

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

et al. 2015

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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

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The effect of physician risk tolerance and the presence of an observation unit on decision making for ED patients with chest pain

Cited by 127 publications

References 25 publications

Guideline-Inconsistent Breast Cancer Screening for Women over 50: A Vignette-Based Survey

Guideline-Inconsistent Breast Cancer Screening for Women over 50: A Vignette-Based Survey

Emergency Physician Perceptions of Medically Unnecessary Advanced Diagnostic Imaging

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

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