Triage Decisions for Emergency Department Patients with Chest Pain: Do Physicians' Risk Attitudes Make the Difference? Steven D. Pearson, MD, MSc, Lee Goldman, MD, MPH, E. John Orav, PhD, Edward Guadagnoli, PhD, Tomas B. Garcia, MD, Paula A. Johnson, MD, MPH, Thomas H. Lee, MD, MSc

OBJECTIVE: To d e t e r m i n e w h e t h e r p h y s i c i a n s ' risk attitudes correlate with their triage d e c i s i o n s for e m e r g e n c y department patients with a c u t e c h e s t pain. DESIGN: Cohort. SETTING- The e m e r g e n c y d e p a r t m e n t o f a u n i v e r s i t y t e a c h ing hospital. PATIENTS: Patients preseDting to the e m e r g e n c y d e p a r t m e n t with a c h i e f c o m p l a i n t o f a c u t e c h e s t pain. PHYSICIANS: AH p h y s i c i a n s w h o were primarily r e s p o n s i b l e for the e m e r g e n c y d e p a r t m e n t triage o f at least o n e patient with a c u t e c h e s t pain from J u l y 1 9 9 0 to J u l y 1 9 9 1 . METHODS. The p h y s i c i a n s ' risk a t t i t u d e s were a s s e s s e d by two methods: 1} a n e w , s i x - q u e s t i o n risk-taklng s c a l e adapted from the J a c k s o n P e r s o n a l i t y I n d e x (JPI), and 2) the S t r e s s from Uncertainty S c a l e (SUS). R E S U L T S : The p h y s i c i a n s w h o had h i g h risk-taklng s c o r e s ("risk seekers") admitted o n l y 31% o f t h e patients t h e y evaluated, compared w i t h s d m J s s i o n rates of 44% for t h e m e d i u m scorers and 53% for the p h y s i c i a n s w h o had l o w risk-taking scores ("risk avoiders"), p < 0 . 0 0 1 . After a d j u s t m e n t for clinical factors, the patients trisged by t h e r i s k - s e e k i n g p h y s i cians had h a l f the odds o f admiJ;sion [odds ratio (OR) 0 . 5 1 , 95% c o n f i d e n c e interval (95% CI) 0 . 2 7 to 0.971, and t h e patients triaged by the risk-avoiding p h y s i c i a n s h a d nearly twice the odds o f a d m i s s i o n (OR 1 . 8 3 , 95% CI 1 . 1 0 to 3 . 0 3 ) of the patients trlaged b y the m e d i u m - r i s k s c o r i n g p h y s i c i a n s . The SUS did n o t correlate s i g n i f i c a n t l y w i t h a d m l ; s i o n rates. Of the 9 2 patients r e l e a s e d h o m e by t h e r i s k - s e e k l n g p h y s i cians, 9 1 (99%) were k n o w n to be alive four to six w e e k s afterwards and o n e w a s lost to follow-up; a m o n g the 6 6 patients released b y the risk-avoidlng p h y s i c i a n s , 6 4 (97%) w e r e known to be alive at four to six w e e k s , o n e w a s l o s t to followup, and o n e died o f i s c h e m i c heart d i s e a s e during a s u b s e quent h o s p i t a l i z a t i o n (p = NS). CONCLUSIONS: The p h y s i c i a n s ' risk a t t i t u d e s as m e a s u r e d by a brief risk-tAk;ng scale correlated s i g n i f i c a n t l y w i t h their rates o f a d m i s s i o n for e m e r g e n c y d e p a r t m e n t patients w i t h acute c h e s t pain. T h e s e data d o n o t s u g g e s t that t h e riskseeking p h y s i c i a n s a c h i e v e d l o w e r a d m i s s i o n rates b y releasing more patients w h o n e e d e d to be in the hospital, but an adequate e v a l u a t i o n o f the a p p r o p r i a t e n e s s o f trlage decisions o f risk-seeking and risk-avoidlng p h y s i c i a n s will require further study. K E Y WORDS: p h y s i c i a n attitudes; risk; triage; d e c i s i o n making; e m e r g e n c y department. J GEN INTERN MED 1 9 9 5 ; 1 0 : 5 5 7 - - 5 6 4 .

ll p h y s i c i a n s are c o n f r o n t e d daily w i t h clinical de-

A cisions t h a t m u s t be m a d e u n d e r c o n d i t i o n s of u n -

certainty a n d risk. Differences a m o n g p h y s i c i a n s in their responses to u n c e r t a i n t y a n d risk m a y be a m o n g the root causes of u n e x p l a i n e d v a r i a t i o n i n physicians" practice p a t t e r n s a n d u s e of resources. ~-3 Despite this hypothesis, the a c t u a l i n f l u e n c e exercised by p h y s i c i a n s ' "risk a t t i t u d e s " i n specific clinical s i t u a t i o n s h a s n o t been extensively s t u d i e d , a n d t h e s t u d i e s t h a t do exist have produced c o n f l i c t i n g results. 4-6 An e v a l u a t i o n of the l i t e r a t u r e o n risk a t t i t u d e s is h a m p e r e d by the existence of m u l t i p l e m e t h o d s b y w h i c h investigators have s o u g h t to c a p t u r e the key e l e m e n t s of p h y s i c i a n s ' b e h a v i o r u n d e r u n c e r t a i n t y a n d risk. Various i n s t r u m e n t s have b e e n developed, adapted, or borrowed to m e a s u r e o v e r l a p p i n g psychological c o n s t r u c t s whose n a m e s i n c l u d e "risk preference," "'tolerance of ambiguity," a n d "reaction to u n c e r t a i n t y . ''4-s In the field of p e r s o n a l i t y psychology, a c o n s t r u c t n a m e d "risk t a k i n g " was e s t a b l i s h e d i n the 1970s as part of overall p e r s o n a l i t y a s s e s s m e n t s . 9 T h e c r i t e r i o n s t a n d a r d m e a s u r e i n t h i s field is the J a c k s o n P e r s o n a l i t y Index (JPI), w h i c h is c o m p o s e d of 16 s u b s c a l e s t h a t include areas s u c h as self-esteem, i n n o v a t i o n , social participation, tolerance, a n d risk t a k i n g . ]o According to the JPI d o c u m e n t a t i o n , a "risk seeker" is d e f i n e d as someone who enjoys a d v e n t u r e s a n d is u n c o n c e r n e d with danger, w h e r e a s a "risk avoider" is c o n s i d e r e d to be cautious, h e s i t a n t , a n d s e c u r i t y - m i n d e d . Despite extensive prospective v a l i d a t i o n of the s u b s c a l e s i n the JPI w i t h actual b e h a v i o r i n a wide r a n g e of s i t u a t i o n s a n d oc-

R e c e i v e d f r o m t h e D e p a r t m e n t o f A m b u l a t o r y Care a n d Prevention, Harvard M e d i c a l School a n d H a r v a r d C o m m u n i t y Health Plan; a n d the Section f o r Clinical E p i d e m i o l o g y , Division of General Medicine, the C a r d i o v a s c u l a r Division, Dep a r t m e n t o f Medicine, a n d the D e p a r t m e n t o f E m e r g e n c y Medicine, B r i g h a m a n d W o m e n ' s Hospital a n d H a r v a r d M e d i c a l School. Boston, M a s s a c h u s e t t s . Supported in part b y a g r a n t f r o m the A g e n c y f o r H e a l t h Care Policy a n d R e s e a r c h (RO1-HS06452). Dr. Lee is the recipient o f a n E s t a b l i s h e d Investigator A w a r d ( 9 0 0 1 9 } f r o m the A m e r i c a n Heart Association. A d d r e s s c o r r e s p o n d e n c e a n d reprint requests to Dr. Lee: Section f o r Clinical E p i d e m i o l o g y , B r i g h a m a n d W o m e n ' s Hospital. 75 Francis Street, Boston, MA 02115. 557

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cupations, we are u n a w a r e of a n y a t t e m p t to u s e the r i s k - t a k i n g s u b s c a l e or to a d a p t it for the p u r p o s e of s t u d y i n g p h y s i c i a n s ' behavior. In 1990, Gerrity a n d colleagues first described a n e w m e a s u r e of p h y s i c i a n " r e a c t i o n to u n c e r t a i n t y " t h a t is d i s t i n g u i s h e d b y its w e l l - d o c u m e n t e d p s y c h o m e t r i c properties a n d its relevance to medical s i t u a t i o n s . 7 The Gerrity q u e s t i o n n a i r e c o m b i n e s the S t r e s s from Uncertainty S u b s c a l e {SUS} a n d the R e l u c t a n c e to Disclose U n c e r t a i n t y Subscale. Developed b y p h y s i c i a n s a n d focused only on issues of clinical u n c e r t a i n t y , Gerrity et al.'s m e a s u r e of risk a t t i t u d e s is the only one whose specific target is the s t u d y of the r e l a t i o n s h i p b e t w e e n physicians" risk a t t i t u d e s a n d clinical decisions. However, validation s t u d i e s c o m p a r i n g scores o n t h i s m e a s u r e w i t h actual p h y s i c i a n b e h a v i o r are n o t yet available. In this s t u d y we u s e d b o t h the SUS from the Gerrity m e a s u r e a n d c e r t a i n a d a p t e d q u e s t i o n s from the JPI r i s k - t a k i n g s u b s c a l e to m e a s u r e i n t w o different ways the risk a t t i t u d e s of p h y s i c i a n s at o u r i n s t i t u t i o n . To evaluate the i m p o r t a n c e of differences o n these measures a m o n g p h y s i c i a n s , we c o m p a r e d the p h y s i c i a n s ' scores with t h e i r a c t u a l b e h a v i o r i n m a k i n g a clinical decision f r a u g h t with u n c e r t a i n t y a n d r i s k - - t h e decision to release h o m e p a t i e n t s with a c u t e c h e s t p a i n who have p r e s e n t e d to a n e m e r g e n c y d e p a r t m e n t .

METHODS Patient Enrollment This s t u d y was p e r f o r m e d w i t h i n a larger time-series trial of the u s e of a p r e d i c t i o n rule to modify clinical m a n a g e m e n t of p a t i e n t s with a c u t e chest p a i n . ~ (In t h i s study, a n o n i n t r u s i v e e d u c a t i o n a l i n t e r v e n t i o n a i m e d at decreasing a d m i s s i o n rates a n d s h o r t e n i n g l e n g t h s of stay was tested d u r i n g six 14-week cycles, each i n c l u d ing a five-week i n t e r v e n t i o n period a n d a five-week control period s e p a r a t e d b y two-week " w a s h o u t " periods. This i n t e r v e n t i o n c o n s i s t e d of u s i n g s t i c k e r s a n d flowsheets to provide triage r e c o m m e n d a t i o n s for p a t i e n t s with low clinical risks of c o m p l i c a t i o n s . No i m p a c t o n r e s o u r c e u t i l i z a t i o n f r o m t h i s i n t e r v e n t i o n w a s detected.) Eligible p a t i e n t s i n c l u d e d all p e r s o n s aged 30 years or more who p r e s e n t e d to the e m e r g e n c y d e p a r t m e n t of the B r i g h a m a n d W o m e n ' s Hospital from J u l y 2, 1990, to J u l y 1, 1991, w i t h a p r i m a r y c o m p l a i n t of c h e s t p a i n u n e x p l a i n e d by o b v i o u s local t r a u m a or a b n o r m a l i t i e s on a chest radiograph. C h e s t r a d i o g r a p h y a n d electrocardiography (ECG) were p e r f o r m e d at the e v a l u a t i n g physicians" discretion. If ECG was n o t performed i n the emergency d e p a r t m e n t , the p a t i e n t was n o t i n c l u d e d i n the study, The s t u d y d e s i g n was approved by the Instit u t i o n a l Review Board of B r i g h a m a n d W o m e n ' s Hospital. Patients" clinical d a t a were recorded by the exam-

]GIM

i n i n g p h y s i c i a n i n the e m e r g e n c y d e p a r t m e n t o n a form used for the e v a l u a t i o n of all p a t i e n t s with c h e s t p a i n . If the p h y s i c i a n did n o t u s e t h i s form, the p a t i e n t data were gathered later from the c h a r t by a r e s e a r c h n u r s e blinded to the p a t i e n t ' s p o s t - e m e r g e n c y d e p a r t m e n t course.

Clinical Outcomes The final d i a g n o s i s of a c u t e myocardial i n f a r c t i o n (AMI) was b a s e d o n previously p u b l i s h e d criteria, ~2 inc l u d i n g 1) c h a r a c t e r i s t i c e v o l u t i o n of s e r u m e n z y m e levels, 2) electrocardiographic c h a n g e s , a n d 3) s u d d e n u n e x p l a i n e d d e a t h w i t h i n 72 h o u r s of p r e s e n t a t i o n . For p a t i e n t s released from the e m e r g e n c y department, a postcard was s e n t to seek c o n s e n t for t e l e p h o n e contact to d e t e r m i n e clinical s t a t u s at four to six weeks after initial p r e s e n t a t i o n . If c o n s e n t for p h o n e c o n t a c t was n o t o b t a i n e d or c o n t a c t a t t e m p t s were u n s u c c e s s f u l , chart and/or c o m p u t e r review was performed to seek information that would allow a d e t e r m i n a t i o n of w h e t h e r the p a t i e n t was alive at the t i m e of follow-up.

Physicians All p h y s i c i a n s who evaluated at least o n e p a t i e n t with chest p a i n i n the e m e r g e n c y d e p a r t m e n t d u r i n g the s t u d y period were eligible for the study. P h y s i c i a n s were either board-certified or -eligible e m e r g e n c y medicine a t t e n d i n g p h y s i c i a n s , i n t e r n a l m e d i c i n e h o u s e s t a f f [postgraduate year one (PGY-1), PGY-2, a n d PGY-3 residents] d u r i n g m o n t h - l o n g e m e r g e n c y d e p a r t m e n t rotations, or p h y s i c i a n s i n clinical fellowships who covered some e v e n i n g shifts as a t t e n d i n g p h y s i c i a n s o n a parttime basis. Patients with a c u t e c h e s t p a i n p r e s e n t i n g to the emergency d e p a r t m e n t d u r i n g t h i s s t u d y were placed i n one of several "acute" r o o m s w i t h cardiac m o n i t o r i n g capability. P h y s i c i a n s were a s s i g n e d i n a r o t a t i n g m a n ner to these r o o m s a n d did n o t have a n y role i n determ i n i n g w h i c h p a t i e n t s they evaluated. E a c h p a t i e n t was assigned to a single p h y s i c i a n who, following clinical evaluation, held the p r i m a r y r e s p o n s i b i l i t y for the triage decision to release or a d m i t the p a t i e n t . T h e e x a m i n i n g p h y s i c i a n s f r e q u e n t l y d i s c u s s e d t h e i r clinical impressions with the e m e r g e n c y d e p a r t m e n t a t t e n d i n g physician and/or the referring p h y s i c i a n . However, each physician in the emergency department retained and exercised considerable i n d e p e n d e n c e i n deciding w h e t h e r p a t i e n t s were u l t i m a t e l y hospitalized. T h e a t t e n d i n g p h y s i c i a n s could overrule the triage d e c i s i o n of a resident, b u t at o u r i n s t i t u t i o n t h i s was u n c o m m o n at the time this s t u d y was performed.

Risk of Acute Myocardial Infarction To evaluate w h e t h e r the physicians" risk a t t i t u d e s had variable effects o n triage d e c i s i o n s for p a t i e n t s at

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different clinical risks of acute ischemic heart disease, we a n a l y z e d t h e p a t i e n t s " c l i n i c a l d a t a f r o m t h e e m e r gency department using a previously validated predict i o n r u l e to s t r a t i f y t h e m a c c o r d i n g to t h e i r p r e d i c t e d r i s k s for AMI. ~a F o r t h e p u r p o s e s o f o u r a n a l y s e s , t h e p a t i e n t s ' r i s k s f o r AMI w e r e c a t e g o r i z e d a s b e i n g e i t h e r h i g h - r i s k ( 2 5 % o r more}, m e d i u m - r i s k ( b e t w e e n 8 % a n d 24%), o r l o w - r i s k (7% o r less}.

Physicians' Risk Attitude Scores The physicians" risk attitudes were assessed through a w r i t t e n q u e s t i o n n a i r e d i s t r i b u t e d s i m u l t a n e o u s l y to all eligible p h y s i c i a n s a t t h e e n d o f t h e s t u d y p e r i o d i n July 1991. The first of the risk attitude measures we c h o s e to i n c l u d e i n o u r q u e s t i o n n a i r e w a s a g r o u p o f questions selected and adapted from the JPI. The JPI is c o m p o s e d of 3 2 0 q u e s t i o n s e q u a l l y d i v i d e d i n t o 16 s u b s c a l e s , o n e o f w h i c h c o n c e r n s r i s k t a k i n g . We c o n d u c t e d a pilot study in which physicians often thought that the entire subscale was too lengthy and that the financial, social, a n d p h y s i c a l r i s k q u e s t i o n s i n t h e s u b s c a l e w o u l d s e e m h u m o r o u s a n d d i s t r a c t i n g t o p h y s i c i a n s . We t h e r e fore n a r r o w e d t h e s e l e c t i o n for o u r s t u d y q u e s t i o n n a i r e to s i x of t h e 2 0 q u e s t i o n s i n t h e J P I r i s k - t a k i n g s u b s c a l e ( T a b l e 1). T h e o r i g i n a l J P I f o r m a t h a d q u e s t i o n s w i t h " y e s / n o " r e s p o n s e s , b u t to m a i n t a i n a c o m m o n f o r m a t with other questions in our study questionnaire, we adapted the response format to a six-point Likert scale r a n g i n g f r o m " s t r o n g l y a g r e e " to " s t r o n g l y d i s a g r e e , ' " w i t h o u t l a b e l s for t h e i n t e r m e d i a t e c a t e g o r i e s . T h e s e c o n d m e a s u r e of r i s k a t t i t u d e s i n o u r s t u d y questionnaire was based on Gerrity et al.'s published " r e a c t i o n to u n c e r t a i n t y " m e a s u r e . 7 F o r b r e v i t y w e i n cluded in our questionnaire only one of the two subs c a l e s of t h i s m e a s u r e , t h e S U S , w h i c h h a s b e t t e r internal reliability than the second subscale, the Reluct a n c e to D i s c l o s e U n c e r t a i n t y S c a l e . T h e S U S w a s u s e d i n i t s e n t i r e t y a n d i n i t s o r i g i n a l f o r m a t : 13 q u e s t i o n s i n a s i x - p o i n t L i k e r t s c a l e r a n g i n g f r o m " s t r o n g l y agree'" to " s t r o n g l y d i s a g r e e " ( T a b l e 2). R i s k - t a k i n g a n d S U S s c o r e s for t h e i n d i v i d u a l p h y s i c i a n s w e r e c a l c u l a t e d s e p a r a t e l y b y s u m m i n g t h e i r respective six-point Likert responses and multiplying them by a correction factor for any missing responses that assumes that the average of available responses applies to m i s s i n g r e s p o n s e s { T a b l e s 1 a n d 2). F o r e a c h r i s k attitude measure, we divided the physicians into three categories based on their raw scores: high scorers were defined as those scoring more than one standard deviation above the mean, middle scorers occupied the midr a n g e , a n d low s c o r e r s s c o r e d m o r e t h a n o n e s t a n d a r d deviation below the mean. Because low scores on the S U S i n d i c a t e low s t r e s s f r o m u n c e r t a i n t y , t h e S U S s c o r e s were reversed when they were compared with the riskt a k i n g s c o r e s s o t h a t l o w s c o r e s o n t h e S U S w o u l d correspond appropriately to high risk-taking scores.

Table t Physician Risk Attitudes Measured on the Risk-taking Scale* 1. I enjoy taking risks. 2. I try to avoid s i t u a t i o n s t h a t have u n c e r t a i n outcomes. 3. Taking risks does not b o t h e r me if the g a i n s involved are high. 4. I consider security a n i m p o r t a n t element in every aspect of my life. 5. People have told me t h a t I seem to enjoy t a k i n g chances. 6. I rarely, if ever, take risks w h e n there is a n o t h e r alternative. *All questions w e r e a s k e d on a six-point Likert s c a l e f r o m "strongly agree" to "'strongly d i s a g r e e . " R i s k - t a k i n g score = s u m o f r e s p o n s e s x (6/16 - n u m b e r qf m i s s i n g responses]).

Data Analysis A n a l y s i s of v a r i a n c e o r S t u d e n t ' s t - t e s t w a s u s e d to e v a l u a t e t h e r e l a t i o n s h i p of level o f t r a i n i n g to r i s k a t titude measure scores. In multivariate analyses correlating risk attitude scores to triage decisions, hospital admission was used as the dependent variable in logistic r e g r e s s i o n . T h e s e r e g r e s s i o n a n a l y s e s c o n t r o l l e d for p a tient risk category, insurance status, gender, and additional patient clinical data found in previous studies to b e r e l a t e d to a d m i s s i o n r a t e s for p a t i e n t s w i t h a c u t e c h e s t p a i n , i n c l u d i n g : age, l e n g t h o f c h e s t p a i n , q u a l i t y of t h e p a i n d e s c r i b e d a s " ' p r e s s u r e , ' " p a i n s i m i l a r to t h a t of a p r e v i o u s m y o c a r d i a l i n f a r c t i o n o r w o r s e t h a n p r e vious angina, and pain reproduced by positional changes or p a l p a t i o n . 1 4 . ~s

Table 2 Physician Risk Attitudes Measured on the Stress from Uncertainty Subscale [SUS]* 1. The u n c e r t a i n t y of p a t i e n t care often troubles me. 2. Not being sure of w h a t is best for a p a t i e n t is one of the most stressful p a r t s of b e i n g a physician. 3. 1 am tolerant of the u n c e r t a i n t i e s p r e s e n t in p a t i e n t care. 4. I find the u n c e r t a i n t y involved in p a t i e n t care disconcerting. 5. I usually feel a n x i o u s w h e n I a m not sure of a diagnosis. 6. When I a m u n c e r t a i n of a diagnosis. I i m a g i n e all sorts of bad s c e n a r i o s - - p a t i e n t dies, p a t i e n t sues, etc. 7. I am frustrated w h e n I do not know a p a t i e n t ' s diagnosis. 8. I fear b e i n g held a c c o u n t a b l e for the limits of my knowledge. 9. Uncertainty in p a t i e n t care m a k e s me uneasy. 10. I worry a b o u t malpractice w h e n I do n o t k n o w a p a t i e n t ' s diagnosis. 11. The v a s t n e s s of the i n f o r m a t i o n p h y s i c i a n s are expected to know overwhelms me. 12. I frequently wish I h a d gone into a specialty or subspecialty t h a t would m i n i m i z e the u n c e r t a i n t i e s of p a t i e n t care. 13. I am quite comfortable with the u n c e r t a i n t y in p a t i e n t care. *All questions w e r e a s k e d on a six-point Likert s c a l e f r o m "'strongly agree'" to "strongly disagree. " S U S score s u m of r e s p o n s e s × (13/[13 - n u m b e r of m i s s i n g responses]).

560

P e a r s o n et al., E D Triage D e c i s i o n s a n d R i s k A t t i t u d e s

Given t h a t some p h y s i c i a n s saw more t h a n one patient, we u s e d the general e s t i m a t i n g e q u a t i o n (GEE) program to a d j u s t for the possibility of i n t r a p h y s i c i a n correlation i n triage decisions. 16

RESULTS A total of 129 p h y s i c i a n s evaluated 1,147 p a t i e n t s with acute chest p a i n i n the e m e r g e n c y d e p a r t m e n t d u r ing the s t u d y period. A m o n g the p h y s i c i a n s , 119 (92%) of 129 completed the risk a t t i t u d e q u e s t i o n n a i r e , including 29 i n t e r n s , 27 j u n i o r r e s i d e n t s , 31 s e n i o r residents, a n d 32 e m e r g e n c y d e p a r t m e n t a t t e n d i n g physicians. These 119 p h y s i c i a n s were r e s p o n s i b l e for the triage of 1,097 (96%) of all eligible p a t i e n t s . A m o n g the 1,097 p a t i e n t s , the m e a n age was 54 + 16 years, a n d 570 (52%l were w o m e n . The predictive model classified 663 (60%) as b e i n g at low risk, 2 6 0 (24%) at m e d i u m risk, a n d 91 (8%) at h i g h risk for AMI on the b a s i s of t h e i r e m e r g e n c y d e p a r t m e n t clinical data. Incomplete clinical d a t a r e s u l t e d i n 83 (8%) of p a t i e n t s ' having u n d e t e r m i n e d r i s k s for i n f a r c t i o n . A m o n g all the patients, p h y s i c i a n s u l t i m a t e l y a d m i t t e d 474 (43%) to the hospital, of w h o m 78 (16%) h a d evidence of AMI. No p a t i e n t released h o m e d u r i n g t h i s s t u d y r e t u r n e d to the emergency d e p a r t m e n t w i t h i n 48 h o u r s with f u r t h e r c o m p l a i n t s of chest p a i n . A single p a t i e n t r e t u r n e d after 72 h o u r s a n d was a d m i t t e d to the h o s p i t a l b u t did n o t have evidence of AMI.

Risk Attitude Scores The m e a n score o n the r i s k - t a k i n g q u e s t i o n s was 19 + 4, with a r a n g e e x t e n d i n g from 11 to 30. O n e p h y s i c i a n a n s w e r e d only five q u e s t i o n s ; all others h a d complete scores. T h e C r o n b a c h ' s a l p h a for the i n t e r n a l reliability of these six q u e s t i o n s was 0.71. T h o s e 12 physicians who h a d scores h i g h e r t h a n 23 were classified as risk seekers; 91 p h y s i c i a n s h a d scores w i t h i n one s t a n d a r d deviation of the m e a n , a n d 16 p h y s i c i a n s scored less t h a n 15 a n d were therefore categorized as the risk-avoiding group. T h e m e a n SUS score was 36 _+ 8, with a r a n g e from 16 to 58. T h e r e were only four m i s s i n g responses, three from one p h y s i c i a n . T h e 15 p h y s i c i a n s who scored less t h a n 28 were d e s i g n a t e d as the "low stress from u n c e r t a i n t y " group, w h e r e a s 14 physicians scored more t h a n one s t a n d a r d deviation above the m e a n , therefore q u a l i f y i n g as the " h i g h stress from u n c e r t a i n t y " group. Overall, there was a s i g n i f i c a n t correlation b e t w e e n the physicians" r i s k - t a k i n g a n d SUS scores ( S p e a r m a n r a n k correlation = 0.36, p = 0.0001 ). However, the concordance of the i d e n t i f i c a t i o n of the p h y s i c i a n s w i t h extreme scores was poor: of the 50 p h y s i c i a n s classified as either high or low o n e i t h e r the r i s k - t a k i n g s u b s c a l e or the SUS, only seven (14%) were classified i n the h i g h or low category o n b o t h m e a s u r e s .

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Level of t r a i n i n g did n o t have a s i g n i f i c a n t relationship with risk a t t i t u d e scores. T h e a t t e n d i n g p h y s i c i a n s had a m a r g i n a l l y h i g h e r m e a n r i s k - t a k i n g score of 19.3, compared with 18.7 for the h o u s e s t a f f (p = 0.68). O n the SUS, the a t t e n d i n g p h y s i c i a n s h a d a lower m e a n score, i n d i c a t i n g less s t r e s s from u n c e r t a i n t y (33.7 vs 36.1), b u t this difference did n o t reach statistical significance (p = 0.14). Analyses of v a r i a n c e c o m p a r i n g raw scores o n b o t h risk a t t i t u d e m e a s u r e s w i t h year of t r a i n i n g (PGY-1, PGY-2, PGY-3. or a t t e n d i n g ) also failed to d e m o n s t r a t e a s i g n i f i c a n t r e l a t i o n s h i p .

Risk Attitude Scores and Admission Rates The physicians" scores o n the r i s k - t a k i n g s u b s c a l e correlated s i g n i f i c a n t l y w i t h a d m i s s i o n rates (Fig. 1). The risk avoiders a d m i t t e d 53% of all the p a t i e n t s they saw; the m i d d l e - s c o r i n g p h y s i c i a n s , 44%- a n d the risk seekers, only 31% (p < 0.001). The r i s k - s e e k i n g physicians h a d a d m i s s i o n rates t h a t were statistically significantly lower for the p a t i e n t s at low a n d m e d i u m r i s k s of infarction, a n d they even h a d lower a d m i s s i o n rates for the p a t i e n t s at h i g h risk of i n f a r c t i o n , t h o u g h the difference did not reach statistical significance (p = 0.101. The u n i v a r i a t e correlation of r i s k - t a k i n g score w i t h adm i s s i o n r e m a i n e d s i g n i f i c a n t i n GEE-corrected a n a l y s e s of raw scores (p = 0.008), terciles of raw scores (p = 0.05), or the r i s k - s e e k i n g a n d r i s k - a v o i d i n g categories (p = o . o o 4 ) .

The SUS s c o r e s were n o t s i g n i f i c a n t l y related to adm i s s i o n rates i n u n i v a r i a t e analyses. A l t h o u g h there was a t r e n d for the h i g h - s t r e s s p h y s i c i a n s to a d m i t more p a t i e n t s t h a n the m e d i u m - a n d low-stress p h y s i c i a n s did, this t r e n d was p r e s e n t only for the p a t i e n t s at low risk of i n f a r c t i o n a n d was n o t statistically s i g n i f i c a n t . The lower a d m i s s i o n rates of the r i s k - s e e k i n g physicians were n o t a t t r i b u t a b l e to lower r i s k s of i n f a r c t i o n a m o n g their p a t i e n t s . Despite the r a n d o m a s s i g n m e n t of p a t i e n t s i n the e m e r g e n c y d e p a r t m e n t , the risk-seeking p h y s i c i a n s actually saw p a t i e n t s who h a d a h i g h e r m e a n risk of i n f a r c t i o n t h a n h a d the p a t i e n t s s e e n by the risk-avoiding p h y s i c i a n s (13% vs 8%, p = 0.02). In multivariate a n a l y s e s a d j u s t e d for r i s k of i n f a r c t i o n a n d other clinical factors related to a d m i s s i o n decisions, the risk-taking scores, w h e t h e r analyzed as a raw score or in risk-seeking a n d r i s k - a v o i d i n g categories, r e m a i n e d significantly correlated w i t h a d m i s s i o n r a t e s (Table 3). Using the odds of a d m i s s i o n for p a t i e n t s s e e n b y the m e d i u m - s c o r i n g p h y s i c i a n s a s the baseline, the odds ratio for a d m i s s i o n of p a t i e n t s s e e n b y the r i s k - s e e k i n g p h y s i c i a n s was 0.51 [95% c o n f i d e n c e interval (CI) 0.27 to 0.97]. For the p a t i e n t s s e e n by a r i s k - a v o i d i n g physician, the odds ratio for a d m i s s i o n was 1.83 (95% CI 1.10 to 3.03). W h e n c o m p a r e d w i t h the a d m i s s i o n rate of 44% for the p a t i e n t s s e e n by the m e d i u m r i s k - t a k i n g physicians, these odds ratios t r a n s l a t e i n t o a d m i s s i o n rates a d j u s t e d for clinical factors of 59% for the risk-

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V o l u m e 10, O c t o b e r 1 9 9 5

avoiding p h y s i c i a n s a n d only 28%, less t h a n half t h a t rate, for the r i s k - s e e k i n g p h y s i c i a n s . The SUS scores were also evaluated as raw scores a n d as categorical variables u s i n g the m u l t i v a r i a t e lo-

•

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Risk-seeking physicians

56'1

gistic regression model, a n d they did n o t correlate significantly with the likelihood of a d m i s s i o n . T h e odds ratios for the SUS categorical variables are s h o w n i n Table 4.

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Patient Categories FIGUREt. Physicians' risk attitude scores and hospital admission rates for the patients with acute chest pain they evaluated in the emergency department. In a comparison of scores on questions from the risk-taking scale [top] and the Stress from Uncertainty Subscale (SUS] (bottom], the risk-taking scores alone correlated significantly with the admission rates. In the top graph, the admission rates of the patients seen by the risk-avoiding physicians were lower for all the patients, and this trend was consistent for the patients independently judged to be at low (-~7%), medium (8% to 24%], and high [-~25%] risk of acute myocardial infarction by a previously validated prediction ruleJ3

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P e a r s o n et al., ED Triage D e c i s i o n s a n d R i s k A t t i t u d e s

Table 3 Multivariate Analysis of Physician Risk-taking Scale Scores as Correlates of Hospital Admission Odds Ratio [95% Cl] Risk seekers Risk avoiders High risk of infarction (->25%) per prediction rule Medium risk of infarction (8-25%) per prediction rule Age Health maintenance organization insurance Short (<30 min) duration of pain Long (>24 h) duration of pain Patient gender (female) Pressure quality of pain Pain similar to that of previous infarction or worse than that of previous angina Pain reproduced by palpation Pain reproduced by respiration

0.51 (0.27--0.97) 1.83 (1.10--3.03)

57

(16-199)

4.28 (2.79-6.57) 1.03 (1.02-1.05) 1.62 0.38 0.64 0.61 2.77

(1.05-2.50) (0.22-0.65) (0.39-1.06) (0.40-0.94) (1.85-4.161

5.49 (3.06-9.87) 0.35 (0.22-0.54) 0.34 (0.17-0.65)

Risk Attitudes a n d the A c c u r a c y of Triage Decisions If the p h y s i c i a n s identified by the r i s k - t a k i n g questions as r i s k - s e e k i n g were less likely to a d m i t p a t i e n t s t h a n the r i s k - a v o i d i n g p h y s i c i a n s were, the a c c u r a c y a n d a p p r o p r i a t e n e s s of t h e i r triage d e c i s i o n s b e c o m e a n i m p o r t a n t issue. The lower a d m i s s i o n rate of the riskseeking p h y s i c i a n s s u g g e s t s t h a t they s h o w e d s u p e r i o r specificity for a d m i t t i n g p a t i e n t s w i t h myocardial infarction. The risk seekers a d m i t t e d only 29% of t h e i r p a t i e n t s who did n o t have AMI, c o m p a r e d with the riskavoiding p h y s i c i a n s , who a d m i t t e d 47% of t h e i r p a t i e n t s who did n o t have AMI (p < 0.01). T h e h i g h e r a d m i s s i o n rates of the risk-avoiding p h y s i c i a n s were also reflected in a lower m e a n risk of i n f a r c t i o n for t h e i r a d m i t t e d p a t i e n t s t h a n t h a t for the a d m i t t e d p a t i e n t s of the riskseeking physicians, a l t h o u g h this difference did n o t reach statistical s i g n i f i c a n c e (17% vs 22%, p = 0.20). Although o u r d a t a d e s c r i b i n g p a t i e n t o u t c o m e s were limited, we could find no evidence to s u g g e s t t h a t the higher specificity s h o w n by the r i s k - s e e k i n g p h y s i c i a n s was achieved at the e x p e n s e of releasing h o m e a h i g h e r n u m b e r of p a t i e n t s who h a d m i s s e d u n s t a b l e a n g i n a or AMI. D u r i n g the period of t h i s study, n e i t h e r the riskt a k i n g n o r the r i s k - a v o i d i n g p h y s i c i a n s released a patient who r e t u r n e d to o u r e m e r g e n c y d e p a r t m e n t w i t h i n 48 h o u r s for f u r t h e r e v a l u a t i o n of c h e s t p a i n . In addition, telephone a n d chart follow-up showed that 91 (99%) of the 92 p a t i e n t s d i s c h a r g e d by the r i s k - s e e k i n g phys i c i a n s were k n o w n to be alive four to six weeks after evaluation i n the e m e r g e n c y d e p a r t m e n t ; one p a t i e n t ' s s t a t u s r e m a i n s u n k n o w n . A m o n g the 66 p a t i e n t s released by the r i s k - a v o i d i n g p h y s i c i a n s , 64 (97%) were

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k n o w n to be alive four weeks later, one p a t i e n t ' s s t a t u s is u n k n o w n , a n d one p a t i e n t died. T h i s p a t i e n t was a 94-year-old m a n who r e t u r n e d w i t h r e c u r r e n t c h e s t p a i n to the e m e r g e n c y d e p a r t m e n t seven days after i n i t i a l evaluation, was a d m i t t e d to the hospital for i s c h e m i c heart disease, a n d died seven days after a d m i s s i o n of progressive cardiac i s c h e m i a u n a m e n a b l e to f u r t h e r treatment. Although n o p a t i e n t who h a d k n o w n AMI was released by either a r i s k - s e e k i n g or a r i s k - a v o i d i n g physician d u r i n g the s t u d y period, the total n u m b e r of patients who h a d AMIs was too small to evaluate a d e q u a t e l y w h e t h e r the i n c r e a s e d a d m i s s i o n specificity of the riskseeking p h y s i c i a n s was achieved w i t h o u t the e x p e n s e of decreased sensitivity.

DISCUSSION Risk a n d u n c e r t a i n t y , w h e t h e r c a u s e d by p r o b l e m s of diagnosis, a m b i g u i t i e s of t r e a t m e n t , the u n p r e d i c t ability of p a t i e n t s ' r e s p o n s e s , or the i n t a n g i b i l i t y a n d t r a n s i e n c e of p a t i e n t s ' values, p e r m e a t e the "scientific" elements of a n y medical decision. P h y s i c i a n s face irreducible u n c e r t a i n t y i n the triage d e c i s i o n for chest p a i n p a t i e n t s in the e m e r g e n c y d e p a r t m e n t . They m u s t rely on a subjective clinical a s s e s s m e n t of a p a t i e n t ' s risk i n deciding w h e t h e r a p a t i e n t c a n safely r e t u r n home. T h i s u n c e r t a i n t y is m a g n i f i e d by the s e r i o u s risks t h a t c a n follow a "missed" d i a g n o s i s of a c u t e cardiac ischemia. In one report, p a t i e n t s m i s t a k e n l y released from the emergency d e p a r t m e n t with u n r e c o g n i z e d AMIs had more t h a n twice the mortality rate of p a t i e n t s w h o were correctly a d m i t t e d for their infarctions.~7 Not s u r p r i s i n g l y , p h y s i c i a n s a d m i t m a n y c h e s t p a i n p a t i e n t s who are at low risk of h a v i n g a c u t e i s c h e m i a a n d who eventually show n o evidence of c o r o n a r y artery disease. 18.19 Few s t u d i e s have a t t e m p t e d to evaluate w h e t h e r differences a m o n g p h y s i c i a n s i n t h e i r r e s p o n s e s to u n c e r tainty a n d risk correlate with v a r i a t i o n i n a c t u a l clinical decisions.4-6. 20. 2~ O u r d a t a s u g g e s t t h a t p h y s i c i a n s ' attitudes toward risk m a y lead to s i g n i f i c a n t v a r i a t i o n i n the way they m a k e triage d e c i s i o n s for p a t i e n t s w i t h chest p a i n i n the e m e r g e n c y d e p a r t m e n t . Scores o n the adapted q u e s t i o n s from the JPI correlated c o n s i s t e n t l y with the triage d e c i s i o n s of o u r p h y s i c i a n s , s h o w i n g t h a t the risk-avoiding p h y s i c i a n s were significantly more likely to a d m i t p a t i e n t s t h a n were those p h y s i c i a n s who scored in the r i s k - s e e k i n g e n d of the s p e c t r u m . After a d j u s t m e n t for clinical factors, the p a t i e n t s evaluated by the risk-avoiding p h y s i c i a n s h a d n e a r l y 3.5 t i m e s the odds of a d m i s s i o n of those of the p a t i e n t s s e e n by the riskseeking p h y s i c i a n s . O u r analysis of the r e l a t i o n s h i p b e t w e e n i n d i v i d u a l p h y s i c i a n s ' risk a t t i t u d e s a n d specific triage d e c i s i o n s was complicated by the f r e q u e n t p a r t i c i p a t i o n of multiple p h y s i c i a n s i n d e c i d i n g w h e t h e r a p a t i e n t s h o u l d be

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V o l u m e 10, October 1995

hospitalized. In a d d i t i o n , risk a t t i t u d e s were n o t assessed at the exact time of each triage decision, b u t rather at the e n d of the study, w h e n s o m e p h y s i c i a n s were still in the e m e r g e n c y d e p a r t m e n t , b u t others res p o n d i n g to the q u e s t i o n n a i r e m a y have b e e n nearly a year away from t h e i r last triage d e c i s i o n s for a p a t i e n t with chest pain. F u r t h e r clinical experience in the interim may have affected some p h y s i c i a n s ' r e s p o n s e s to our survey. T h e s e l i m i t a t i o n s , however, s h o u l d have produced results biased toward f i n d i n g n o s t r o n g correlation between i n d i v i d u a l p h y s i c i a n s ' risk a t t i t u d e s a n d their triage decisions. F u r t h e r r e s e a r c h will be n e e d e d to clarify how clinical experience affects risk a t t i t u d e s . It is possible t h a t risk a t t i t u d e s could have influenced how p h y s i c i a n s recorded t h e i r i n t e r p r e t a t i o n s of the ECG a n d o t h e r clinical factors u s e d i n the determ i n a t i o n of "objective" p a t i e n t risk for myocardial infarction. P h y s i c i a n s who are risk-averse m i g h t be pres u m e d to err o n the side of i n t e r p r e t i n g ECGs more conservatively a n d generally overestimating p a t i e n t s ' risks for AMI. If this were the case, however, t h e n o u r adj u s t m e n t for these clinical factors i n m u l t i v a r i a t e analyses would t e n d to d i m i n i s h the i n d e p e n d e n t correlation of the risk a t t i t u d e scores w i t h triage decisions. Did the r i s k - a v o i d i n g p h y s i c i a n s a d m i t too m a n y p a t i e n t s ? Or, o n the other h a n d , did the r i s k - s e e k i n g p h y s i c i a n s achieve lower h o s p i t a l i z a t i o n rates by releasing home more p a t i e n t s who h a d " m i s s e d " u n s t a b l e angina or myocardial i n f a r c t i o n ? O u r s t u d y was n o t designed to a n s w e r these q u e s t i o n s . Nevertheless, a m o n g the p a t i e n t s released h o m e by the r i s k - s e e k i n g physicians, the lack of a n y k n o w n d e a t h s at four to six weeks, coupled with the lack of a n y e m e r g e n t r e a d m i s s i o n s to our hospital w i t h i n 48 h o u r s , s u g g e s t s t h a t the riskseeking physicians did n o t achieve lower a d m i s s i o n rates by s e n d i n g h o m e p a t i e n t s who n e e d e d to be i n the hospital. O u r data lack s u f f i c i e n t power to a d d r e s s these q u e s t i o n s adequately, a n d a full d e t e r m i n a t i o n of the a p p r o p r i a t e n e s s of triage d e c i s i o n s of r i s k - s e e k i n g vs risk-avoiding p h y s i c i a n s will r e q u i r e f u r t h e r study. Our data s u p p o r t the h y p o t h e s i z e d role of risk attitudes i n c r e a t i n g u n e x p l a i n e d v a r i a t i o n s i n medical care. The idea t h a t risk a t t i t u d e s lead to v a r i a t i o n i n medical d e c i s i o n m a k i n g , w i t h a t t e n d a n t c o n s e q u e n c e s for the quality a n d / o r cost of care, raises the q u e s t i o n of w h e t h e r p h y s i c i a n s ' risk a t t i t u d e s c a n be c h a n g e d to s u p p o r t a clinical goal, i.e., the r e d u c t i o n of u n n e c e s s a r y hospital a d m i s s i o n s for c h e s t p a i n . However, scores o n the r i s k - t a k i n g q u e s t i o n s did n o t correlate with increasing clinical experience, a n d it m a y be i m p o s s i b l e to devise a n i n t e r v e n t i o n to c h a n g e deeply i n g r a i n e d risk attitudes. For clinical d e c i s i o n s i n w h i c h p h y s i c i a n s ' risk a t t i t u d e s play a n i m p o r t a n t role, it m a y be more practical to consider u s i n g practice g u i d e l i n e s to seek high levels of quality a n d efficiency by g u i d i n g d e c i s i o n s to a n acceptable r a n g e b e t w e e n risk-averse a n d r i s k - s e e k i n g practice styles.

Table 4 Multivariate Analysis of Physician Stress from Uncertainty Subscole [SUS] Scores as Correlates of Hospital Admission Odds Ratio [95%

Cl] Low stress High stress

1.07 (0.63-1.81 ) 1.31 (0.77-2.22)

High risk of infarction (>-25%) per prediction rule Medium risk of infarction (8-25%) per prediction rule Age Health maintenance organization insurance Short (<30 min) duration of pain Long (>24 h) duration of pain Patient gender (female) Pressure quality of pain Pain similar to that of previous infarction or worse than that of previous angina Pain reproduced by palpation Pain reproduced by respiration

56

(16-192)

3.93 (2.53-6.09) 1.03 {1.02-1.04) 1.57 0.38 0.62 0.62 2.62

( 1.02-2.42) (0.22-0.65) (0.38-1.01) (0.40-1.00) (1.75-3.94)

5.53 (3.10-9.88) 0.3610.23-0.57l 0.34(0.17-0.69)

Our data m a y s u g g e s t to some the o p t i o n of "screening" p h y s i c i a n s for t h e i r risk a t t i t u d e s prior to h i r i n g them or p l a c i n g t h e m i n p a r t i c u l a r clinical settings. S i m ilar to the way in w h i c h h e a l t h care i n s u r e r s have s o u g h t to steer p a t i e n t s toward p r i m a r y care providers in the belief t h a t they provide care of the s a m e q u a l i t y w i t h lower resource use, 22 it m a y seem a logical e x t e n s i o n to consider favoring p h y s i c i a n s whose risk a t t i t u d e s suggest t h a t they m a y be "risk seekers," w i t h c o r r e s p o n d ingly p a r s i m o n i o u s practice styles. We believe t h a t a n y plan to use risk a t t i t u d e profiles to hire or place physicians would be p r e m a t u r e if b a s e d solely o n this report. Given the p o t e n t i a l for conflict of interest, we also feel that the ethics of a n y s u c h s t r a t e g y are o p e n to s e r i o u s question. Whether risk a t t i t u d e s b e c o m e a target for i n t e r v e n tions or s c r e e n i n g , the c o n c e r n r e g a r d i n g u n e x p l a i n e d variation i n medical care is likely to c o n t i n u e to foster a n i n t e r e s t in how risk a t t i t u d e s a n d o t h e r s u b t l e factors influence the d e c i s i o n m a k i n g of p h y s i c i a n s a n d t h e i r patients. The a d a p t e d r i s k - t a k i n g q u e s t i o n s u s e d i n t h i s study may prove useful i n o t h e r s e t t i n g s to d e t e r m i n e whether risk attitudes are related to variation in a broader range of practice p a t t e r n s .

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