Emergency physicians' fear of malpractice in evaluating patients with possible acute cardiac ischemia.
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.


CONCLUSIONS
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.
Katz
David A
DA
Department of Medicine, University of Iowa Carver College of Medicine, Center for Research in the Implementation of Innovative Strategies in Practice, Iowa City VA Medical Center, Iowa City, IA, USA. david-katz@uiowa.edu
Williams
Geoffrey C
GC
Brown
Roger L
RL
Aufderheide
Tom P
TP
Bogner
Mark
M
Rahko
Peter S
PS
Selker
Harry P
HP
D000328:Adult; D000789:Angina, Unstable / Q000175:diagnosis / Q000209:etiology; D001291:Attitude of Health Personnel; D002637:Chest Pain / Q000175:diagnosis; D003675:Defensive Medicine / Q000706:statistics & numerical data*; D003937:Diagnosis, Differential; D004635:Emergency Medicine / Q000706:statistics & numerical data*; D005239:Fear; D005260:Female; D019538:Health Care Surveys; D006801:Humans; D016015:Logistic Models; D008297:Male; D008962:Models, Theoretical; D015999:Multivariate Analysis; D017202:Myocardial Ischemia / Q000150:complications / Q000175:diagnosis*; D016017:Odds Ratio; D017064:Process Assessment, Health Care; D011364:Professional Practice / Q000706:statistics & numerical data*; D018570:Risk Assessment / Q000379:methods; D012309:Risk-Taking; D014218:Triage / Q000379:methods; D014481:United States