SAN FRANCISCO – Liability concerns may drive emergency physicians’ decisions regarding patients with possible cardiac conditions, based on the results of two studies presented at the Scientific Assembly of the American College of Emergency Physicians.
Many emergency physicians weighed legal concerns more heavily than actual risk when considering whether to admit a patient for acute coronary syndrome, concluded Dr. David H. Newman and his colleagues.
The conclusion was based on an observational, matched-pairs survey conducted at the emergency departments of St. Luke’s Hospital and Roosevelt Hospital in New York. Patients who were admitted "primarily for acute coronary syndrome" were surveyed after they had discussed their admission with the physician. The admitting doctor also completed a survey after communicating with the patient.
Both were asked whether risk and prognosis were discussed, as well as about the perceived potential benefits of admission and perceived primary purpose of admission.
"Doctors and patients in the emergency department are communicating poorly about the risks of death and heart attack, and this is something we need to fix."
When asked to place themselves in the same position as the patient they had just evaluated, physicians often said that they would not have chosen admission for themselves but had admitted the patient, said Dr. Newman, director of clinical research in the department of emergency medicine at Mount Sinai School of Medicine in New York.
During the 18 months of the study, 849 surveys were completed. All patients had primary or secondary complaints of chest pain. Just over half were men. One-third were black, 24% were Hispanic, 23% were white, and 19% were "other" or did not report a race. The largest proportion had attended some high school or graduated (39%), 25% had attended college, 14% had a bachelor’s degree, and 15% had a graduate or professional degree (Ann. Emerg. Med. 2011;58:S210).
Dr. Newman said in an interview that he and his colleagues were surprised to see that education level was not strongly correlated with risk communication or with agreement between the physician and the patient about true risk.
In a post hoc analysis, the authors calculated a mean risk of less than 5% for death, myocardial infarction, or revascularization within 30 days.
The physicians, however, estimated a mean risk for these outcomes of 15%, and patients estimated their risk at 33%.
One-third of patients and 48% of physicians said that coronary risk (the main reason for admission) had not been part of their discussion about admitting the patient. When coronary risk was discussed, agreement between the physician and the patient about the patient’s level of risk was 0.38 (about 40% more likely to agree, compared with random chance).
In 11% of cases, physicians said that concern about liability was one of the reasons for admission. That concern likely represents millions of dollars in health care spending, Dr. Newman said.
In 27% of the cases, the doctor reported that if they were a patient with the same risk, they would not stay overnight.
The results hint that "something is affecting patients’ decision to stay even when someone with a theoretically much more complete understanding of the risks – the doctor – would not stay," Dr. Newman said.
"It is possible that physicians do not recognize the degree to which legal concerns affect these conversations, or perhaps other system pressures [such as] financial incentives, crowding, resource utilization, [or] time are affecting this conversation," he said. "What we can say with confidence is this: Doctors and patients in the emergency department are communicating poorly about the risks of death and heart attack, and this is something we need to fix."
In another study, Dr. Patrick J. Lenehan of Morristown (N.J.) Hospital and colleagues found that a decreasing number of congestive heart failure patients were discharged from the emergency department in 1996-2010.
"It is possible that physicians do not recognize the degree to which legal concerns affect these conversations."
The authors retrospectively reviewed emergency department visits to 27 suburban, urban, and rural New York and New Jersey hospitals. The facilities had 18,000-72,000 annual visits. Using ICD9 codes, the researched identified patients who had likely CHF. This group included those who had CHF, heart failure, or pulmonary edema as a primary diagnosis, or as a secondary diagnosis if the primary was shortness of breath or dyspnea (Ann. Emerg. Med. 2011;58:S237).
Of 6.6 million emergency department visits, 82,230 (1%) were for CHF. Half of the patients were women, and their mean age was 72 years. The authors found that there was a 63% decrease in the number of patients discharged from 1996 to 2010. In 1996, 24% were discharged. By 2010, only 9% were discharged.