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.

项目概要： 个体医生的决策是医疗保健差异程度的重要决定因素 美国的实践 急诊室 (ED) 为研究疾病的决定因素提供了理想的环境 知道决策中风险规避的根本重要性，我们 风险规避可能对急诊医生 (EP) 产生更大的影响 因为紧急护理的高风险和不确定性。 这项研究将重点关注风险规避和认知封闭需求（NFC），以及可能具有以下特征的相关特征： 这些特征共同转化为一定程度的临床效果。 EP 中的焦虑或强迫性 这种特征在 EP 中的分布尚不清楚，是否存在也不清楚。 这种人格特质对于患者来说是有益的还是有害的，很可能是一个特别焦虑或强迫的 EP。 容易受到过度测试（委托错误）的影响，并且这种过度测试会导致潜在的有害结果 然而，在急诊室环境中，对于某些临床情况，可能会出现过度测试。 急诊室设置可能会通过漏诊和发现潜在的危急诊断来提供保护。 对于大多数 ED 条件，确定更高或更低的测试是否更好，或者是否更好，这只是未知且至关重要的。 迫切需要确定这些特征是否与更好的结果相关。 与 ED 的检查强度和入院决定相关。 对于制定干预措施以教育 EPs 了解其内在的风险规避或设定对风险的预期至关重要。 然而，即使是风险规避和 NFC 的盛行，也存在关键临床状况的理想练习强度水平。 欧洲议会议员之间的关系以及他们与决策之间的关系在很大程度上是未知的。 拟议的研究将结合来自 EP 以及来自高级实践提供商的调查数据 他们在提供紧急护理方面发挥着越来越大的作用——在马萨诸塞州，利用数据来自所有 付款人索赔数据库（我们将通过结合医疗保险索赔数据和马萨诸塞州所有 付款人索赔数据库）来实现三个关键目标，首先，我们将衡量付款人索赔数据库的普遍性和分布。 马萨诸塞州 EP/APP 人群中的风险厌恶和 NFC 然后我们将确定这种关系。 提供者风险规避/NFC 分数与实践强度（实验室测试、成像的数量）之间的关系 最后，我们将检查急诊室的关键临床状况。 练习强度与患者伤害之间的关系，利用患者随机的事实 分配给 EP 之外，我们还揭示了医疗决策中尚未探索的领域。 研究结果将作为制定和实施行为干预措施的基础 指导具有不同风险承受能力水平的提供商做出更标准的管理决策或 管理风险厌恶和可能导致的认知偏差之间的界面。

项目成果

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

马萨诸塞州急诊医生和高级临床医生对风险的态度。

• 发表时间: 2021-10
• 作者: Smulowitz, Peter B;Burke, Ryan C;Ostrovsky, Daniel;Novack, Victor;Isbell, Linda;Landon, Bruce E
• 通讯作者: Landon, Bruce E