Physician Decision Making and Variation in Hospital Admission Rates for Suspected Acute Cardiac Ischemia: A Tale of Two Towns

The authors tested the "uncertainty hypothesis," which holds that variations in rates of hospitalization or surgeries across small geographic areas reflect differences in physicians' decision making when confronting uncertainty. A small-areas variation analysis of suspected acute card...

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Bibliographic Details
Published in:Medical care 1994-11, Vol.32 (11), p.1086-1097
Main Authors: Green, Lee A., Becker, Mark P.
Format: Article
Language:English
Subjects:
Acute Disease
Adolescent
Adult
Aged
Bias
Biological and medical sciences
Chest pain
Child
Child, Preschool
Communities
Confidence Intervals
Coronary care units
Decision Making
Diagnosis-Related Groups
Emergency departments
Female
Health Services Research
Hospital admissions
Humans
Infant
Infant, Newborn
Ischemia
Logistic Models
Male
Medical practice
Medical sciences
Michigan
Middle Aged
Myocardial infarction
Myocardial ischemia
Myocardial Ischemia - classification
Myocardial Ischemia - diagnosis
Myocardial Ischemia - epidemiology
Odds Ratio
Patient Admission - statistics & numerical data
Patient Discharge - statistics & numerical data
Physicians
Practice Patterns, Physicians' - statistics & numerical data
Predictive Value of Tests
Public health. Hygiene
Public health. Hygiene-occupational medicine
Retrospective Studies
Small-Area Analysis
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Summary:The authors tested the "uncertainty hypothesis," which holds that variations in rates of hospitalization or surgeries across small geographic areas reflect differences in physicians' decision making when confronting uncertainty. A small-areas variation analysis of suspected acute cardiac ischemia (ACI) admissions in northern Michigan was performed, and two demographically nearly identical towns differing by a factor of 3 in ACI admission rates were selected. Medical records of all patients evaluated in the emergency departments of these hospitals for suspected ACI in 1988 were abstracted retrospectively. Probabilities of ACI were objectively estimated using the Acute Cardiac Ischemia Time-Insensitive Predictive Instrument. Logistic regression of admission on patient characteristics, other illnesses, probability of ACI, and community revealed no difference in admission decisions between the two hospitals (odds ratio for community = 0.766, 95% confidence interval, 0.542-1.08, n = 787, P > .1). Nearly twice as many patients with ACI presented to the emergency department of the high-admitting hospital as to the low-admitting hospital. The authors conclude that, at least for ACI, population-based area discharge rates do not necessarily reflect case-based decision rates. Drawing inferences regarding physician decision making from discharge or claims datasets may lead to error.
ISSN:0025-7079
1537-1948
DOI:10.1097/00005650-199411000-00002