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

Am J Emerg Med. 2010 Sep;28(7):771-9. doi: 10.1016/j.ajem.2009.03.019. Epub 2010 Feb 25.


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.

MeSH terms

  • Adult
  • Aged
  • Attitude of Health Personnel
  • Burnout, Professional / psychology
  • Chest Pain / diagnosis*
  • Chest Pain / etiology
  • Decision Making*
  • Emergency Medicine / organization & administration*
  • Emergency Service, Hospital / organization & administration
  • Female
  • Hospital Units / organization & administration*
  • Humans
  • Logistic Models
  • Male
  • Malpractice
  • Medical Staff, Hospital / psychology*
  • Middle Aged
  • Multivariate Analysis
  • Observation
  • Patient Admission / statistics & numerical data
  • Pennsylvania
  • Practice Patterns, Physicians' / organization & administration
  • Prospective Studies
  • Risk Assessment
  • Risk-Taking*
  • Surveys and Questionnaires
  • Uncertainty