Emergency Physicians' Fear of Malpractice in Evaluating Patients With Possible Acute Cardiac Ischemia
Received 14 February 2005; received in revised form 6 April 2005; accepted 18 April 2005. published online 14 July 2005.
Study objective
We evaluate the association between emergency physicians' fear of malpractice and the triage and evaluation patterns of patients with symptoms suggestive of acute coronary syndrome.
Methods
We surveyed 33 emergency physicians of 2 university hospitals during the preintervention phase of an implementation trial of the Agency for Health Care Policy and Research Unstable Angina guideline in 1,134 study patients. The survey included a 6-item instrument that addressed concerns about malpractice and a measure of general risk aversion. We used hierarchical logistic regression to model emergency department (ED) triage decisions and diagnostic testing as a function of fear of malpractice, with adjustment for patient characteristics, Agency for Health Care Policy and Research guideline risk group, study site, and clustering by emergency physician.
Results
Overall, emergency physicians in the upper tertile of malpractice fear were less likely to discharge low-risk patients compared with emergency physicians in the lower tertile (adjusted odds ratio [OR] 0.34; 95% confidence interval [CI] 0.12 to 0.99; P=.05). Patients treated by emergency physicians in this group were also more likely to be admitted to an ICU or telemetry bed (adjusted OR 1.7; 95% CI 1.2 to 2.4). In addition, emergency physicians in the upper tertile of malpractice fear were more likely to order chest radiography, as well as cardiac troponin. Malpractice fear accounted for a similar amount of variance after controlling for emergency physicians' risk aversion.
Conclusion
Malpractice fear accounts for significant variability in ED decisionmaking and is associated with increased hospitalization of low-risk patients and increased use of diagnostic tests.
SEE EDITORIAL, P. 534.
From the Department of Medicine, University of Iowa Carver College of Medicine, and the Department of Epidemiology, Center for Research in the Implementation of Innovative Strategies in Practice, Iowa City VA Medical Center, Iowa City, IA (Katz); Departments of Medicine and Clinical and Social Sciences in Psychology, University of Rochester, Rochester, NY (Williams); Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI (Aufderheide); Department of Nursing (Brown), Section of Emergency Medicine (Bogner), and Division of Cardiology (Rahko) at the University of Wisconsin, Madison, WI; and the Institute for Clinical Research and Health Policy Studies, Tufts–New England Medical Center, Boston, MA (Selker)
Address for reprints: David A. Katz, MD, MSc, SE626 GH, University of Iowa Hospitals, 200 Hawkins Drive, Iowa City, IA 52242; 319-353-8622, fax 319-356-3086
Supervising editor: J. Stephan Stapczynski, MD
Author contributions: DAK was responsible for study concept and design and drafting of the manuscript. DAK, TPA, and MB were responsible for acquisition of the data. DAK, GCW, and RLB conducted analysis and interpretation of the data. DAK, GCW, RLB, TPA, MB, PSR, and HPS were involved in critical revision of the manuscript for important intellectual content. RB contributed statistical expertise. DAK and HPS obtained funding. DAK and TPA were responsible for study supervision. DAK takes responsibility for the paper as a whole.
Funding and support: Agency for Healthcare Research and Quality (R01 HS10466), Robert Wood Johnson Foundation Generalist Physician Faculty Scholars Program (Dr. Katz), with supplemental support from the University of Wisconsin Department of Medicine.
Presented at the Society of General Internal Medicine annual meeting, May 2004, Washington, DC.
The views in this article are those of the author(s) and do not necessarily represent the views of the Department of Veterans Affairs.
ABSTRACT