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

• Published in: The American journal of emergency medicine 2010-09, Vol.28 (7), p.771-779
• Main Authors: Pines, Jesse M., MD, MBA, MSCE, Isserman, Joshua A., MS, Szyld, Demian, MD, Dean, Anthony J., MD, McCusker, Christine M., RN, MSN, Hollander, Judd E., MD
• Format: Article
• Language: English
• Subjects: Adult; Aged; Anesthesia. Intensive care medicine. Transfusions. Cell therapy and gene therapy; Angina pectoris; Attitude of Health Personnel; Biological and medical sciences; Burnout, Professional - psychology; Cardiovascular disease; Chest Pain - diagnosis; Chest Pain - etiology; Computed tomography; Decision Making; Emergency; Emergency medical care; Emergency Medicine - organization & administration; Emergency Service, Hospital - organization & administration; Female; Heart attacks; Hospital Units - organization & administration; Hospitals; Humans; Intensive care medicine; Investigative techniques, diagnostic techniques (general aspects); Logistic Models; Male; Malpractice; Medical sciences; Medical Staff, Hospital - psychology; Middle Aged; Multivariate Analysis; Myocardial infarction; Observation; Pain; Patient Admission - statistics & numerical data; Pennsylvania; Physicians; Practice Patterns, Physicians' - organization & administration; Prospective Studies; Radiodiagnosis. Nmr imagery. Nmr spectrometry; Respiratory system; Risk Assessment; Risk aversion; Risk taking; Statistical analysis; Surveys and Questionnaires; Uncertainty
• ISSN: 0735-6757; 1532-8171
• DOI: 10.1016/j.ajem.2009.03.019

Abstract Objectives We sought to determine whether risk tolerance as measured by scales (malpractice fear scale [MFS], risk-taking scale [RTS], and stress from uncertainty scale [SUS]) is associated with decisions to admit or use computed tomography (CT) coronary angiogram and decisions to order cardiac markers in emergency department (ED) patients with chest pain. We also studied if the opening of an ED-based observation unit affected the relationship between risk scales and admission decisions. Methods Data from a prospective study of ED patients 30 years or older with chest pain were used. Risk scales were administered to ED attending physicians who initially evaluated them. Physicians were divided into quartiles for each separate risk scale. Fisher's exact test and logistic regression were used for statistical analysis. Results A total of 2872 patients were evaluated by 31 physicians. The most risk-averse quartile of RTS was associated with higher admission rates (78% vs 68%) and greater use of cardiac markers (83% vs 78%) vs the least risk-averse quartile. This was not true for MFS or SUS. Similar associations were observed in low-risk patients (Thrombolysis in Myocardial Infarction risk score of 0 or 1). The observation unit was not associated with a higher admission rate and did not modify the relationship between risk scales and admission rates. Conclusion The RTS was associated with the decision to admit or use computed tomography coronary angiogram, as well as the use of cardiac markers, whereas the MFS and SUS were not. The observation unit did not affect admission rates and nor did it affect how physician's risk tolerance affects admission decisions.