Risk Aversion, Fear of Malpractice, and Medical Decision Making in the Emergency Department

风险规避、对医疗事故的恐惧与急诊科的医疗决策

• 批准号: 10474364
• 负责人: Bruce E. Landon
• 金额: $ 38.36万
• 依托单位: HARVARD MEDICAL SCHOOL
• 依托单位国家: 美国
• 财政年份: 2019
• 资助国家: 美国
• 起止时间: 2019-09-01 至 2024-08-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10474364
• 关键词: Risk; Aversion; Fear; Malpractice; Medical

Project Summary: Individual physician decision-making is an important determinant of the extent of variation in health care practice in the U.S. The emergency department (ED) presents an ideal setting for studying the determinants of variation in decision-making. Knowing the fundamental importance of risk aversion in lay decision-making, we hypothesize that risk aversion has the potential for an even stronger influence on emergency physicians (EPs) because of the high stakes and uncertain nature of emergency care. This study will focus on risk aversion and Need for Cognitive Closure (NFC), related traits that might have a profound impact on decision-making in the ED. Together, these traits translate into a certain level of clinical anxiety or compulsiveness amongst EPs. The distribution of this trait amongst EPs is unclear, as is whether this personality trait is beneficial or harmful for patients. It is likely that a particularly anxious or compulsive EP will be vulnerable to over-testing (errors of commission), and that this over-testing results in potentially harmful downstream outcomes. Yet, in the ED setting it is possible that for some clinical conditions, over-testing in the ED setting might be protective by minimizing missed diagnoses and picking up on potentially critical diagnoses. It simply is unknown and critical to define for most ED conditions whether higher or lower testing is better, or if a range of testing is associated with better outcomes. A critical need exists to determine whether these traits are associated with the intensity of workups and admission decisions in the ED. Delineating this relationship is essential to devising interventions to educate EPs about their intrinsic risk aversion or to set expectations of an ideal level of practice intensity for key clinical conditions. Yet, even the prevalence of risk aversion and NFC amongst EPs – and the relationship between them and decision-making – is largely unknown. The proposed study will combine survey data from EPs – as well as from Advanced Practice Providers given their increasing role in the provision of emergency care- across Massachusetts with utilization data from an all payer claims database (which we will construct by combining Medicare claims data and the Massachusetts All Payer Claims Database) to accomplish three key aims. First we will measure the prevalence and distribution of risk aversion and NFC in the population of Massachusetts EPs/APPs. We will then determine the relationship between provider risk aversion/NFC scores and practice intensity (the number of laboratory tests, imaging studies, and the frequency of hospital admission) for key clinical conditions in the ED. Finally, we will examine the relationship between practice intensity and patient harm, leveraging the fact that patients are randomly assigned to EPs. In addition to shedding light on a largely unexplored area of medical decision-making, our findings will serve as the foundation for the development and implementation of behavioral interventions aimed at guiding providers with different levels of risk tolerance to more standard management decisions or to managing the interface between risk aversion and the cognitive bias that may result.

项目摘要： 个人身体决策是医疗保健差异程度的重要决定者 在美国练习急诊室（ED）为研究的确定词提供了理想的环境 决策的差异。知道风险规避在外行决策中的基本重要性，我们 假设规避风险有可能对紧急医师（EPS）产生更大的影响 由于急救的高风险和不确定的性质。 这项研究将集中于规避风险和认知封闭的需求（NFC），相关特征可能具有 对急诊室决策的深远影响。这些特征共同转化为一定程度的临床 EPS之间的焦虑或强迫性。这种特征在每股收益之间的分布尚不清楚，是否 这种人格特征对患者有益或有害。可能是特别焦虑或强迫性的EP 将容易受到过度测试（佣金错误），并且这种过度测试会导致潜在有害 下游结果。然而，在ED环境中 ED设置可能会通过最大程度地减少错过的诊断方法并进行潜在的关键诊断来保护。 在大多数ED条件下，无论较高还是更低的测试都更好，或者是至关重要的，或者是否更好 一系列测试与更好的结果有关。存在批判性需求，以确定这些特征是否 与ED中的工作强度和入学决策有关。描述这种关系是 设计干预措施以教育EPS有关其内在风险规避或设定对 关键临床条件的理想实践强度。但是，即使风险规避和NFC的流行率 在每股收益以及它们之间的关系与决策之间 - 在很大程度上是未知的。 拟议的研究将结合来自EPS的调查数据，以及来自高级实践提供者 它们在马萨诸塞州跨马萨诸塞州提供的紧急护理中的作用不断提高，并从一个利用数据中 付款人索赔数据库（我们将通过将Medicare索赔数据和马萨诸塞州的所有内容组合来构建 付款人要求数据库）实现三个关键目标。首先，我们将衡量 马萨诸塞州EPS/APP的人口中的风险规避和NFC风险。然后，我们将确定关系 在提供者风险规避/NFC分数和练习强度之间（实验室测试的数量，成像的数量） 研究，医院入院的频率）在ED中的关键临床状况。最后，我们将检查 实践强度与患者伤害之间的关系，利用了患者是随机的事实 分配给EPS。除了阐明医疗决策的意想不到的领域外，我们的 调查结果将成为开发和实施行为干预措施的基础 指导提供者具有不同级别的风险承受能力的提供商，以实现更标准的管理决策或 管理风险规避和可能导致的认知偏差之间的接口。

项目成果

Attitudes toward risk among emergency physicians and advanced practice clinicians in Massachusetts.

• DOI: 10.1002/emp2.12573
• 发表时间: 2021-10
• 期刊: Journal of the American College of Emergency Physicians open
• 影响因子: 2.3
• 作者: Smulowitz PB;Burke RC;Ostrovsky D;Novack V;Isbell L;Landon BE
• 通讯作者: Landon BE