Quantifying Patient-Physician Communication and Perceptions of Risk During Admissions for Possible Acute Coronary Syndromes.
OBJECTIVE
Disposition decision for patients with possible acute coronary syndrome in the emergency department (ED) is driven primarily by perception of short-term risks. We sought to evaluate communication between patient and physician about these risks by ascertaining the content of discussions surrounding disposition decision.


METHODS
We conducted matched-pair surveys of patients admitted for possible acute coronary syndrome and their physicians in 2 academic, inner-city EDs. After disposition conversation, trained research assistants administered surveys querying perceived and communicated risk estimates and purpose of admission. Primary exclusion criteria were ECG or troponin value diagnostic of acute coronary syndrome. The primary outcome measure was agreement in assessment of the risk of myocardial infarction, defined as the proportion of patient-physician pairs whose risk estimates were within 10% of each other.


RESULTS
A total of 425 patient-physician survey pairs were collected. Fifty-three percent of patients were men. Patients reported discussing the likelihood of their symptoms' being due to myocardial infarction in 65% of cases, whereas physicians reported this in 46%. After their discussion, physicians' (n=415) median estimate of short-term risk was 5% (95% confidence interval [CI] 3% to 7%), whereas patients' (n=401) was 8% (95% CI 5% to 11%). Most patients (63%; 95% CI 57% to 67%) reported that this estimate remained the same or increased after their conversation. Risk agreement within 10% occurred in 36% of cases (n=404; 95% CI 32% to 41%). Patients' median estimates of the mortality of myocardial infarction at home versus in the hospital were 80% (n=398; 95% CI 76% to 84%) and 10% (n=390; 95% CI 7% to 13%), respectively, whereas physician estimates were 15% (n=403; 95% CI 12% to 18%) and 10% (n=398; 95% CI 7% to 13%).


CONCLUSIONS
Our survey demonstrates poor communication, with overestimation of both the risks of myocardial infarction and potential benefit of hospital admission. These findings suggest that communication surrounding disposition decisions in chest pain patients may at times be ineffective or misleading.
Icahn School of Medicine at Mount Sinai, New York, NY.
David H
DH
Newman
Albert Einstein College of Medicine, New York, NY.
Brian
B
Ackerman
Rutgers-Robert Wood Johnson Medical School, Piscataway, NJ.
Matthew L
ML
Kraushar
Columbia University College of Physicians and Surgeons, New York, NY.
Margo H
MH
Lederhandler
Florida International University Herbert Wertheim College of Medicine, Miami, FL.
Amal
A
Masri
Weill Cornell Medical College, New York, NY.
Anna
A
Starikov
Howard University College of Medicine, Washington, DC.
Daisy T
DT
Tsao
Duke University School of Medicine, Durham, NC. Electronic address: harvey.p.meyers@vanderbilt.edu.
H Pendell
HP
Meyers
Icahn School of Medicine at Mount Sinai, New York, NY.
Kaushal H
KH
Shah
D054058:Acute Coronary Syndrome / Q000175:diagnosis* / Q000523:psychology; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003142:Communication; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000175:diagnosis / Q000523:psychology; D010343:Patient Admission / Q000706:statistics & numerical data; D010817:Physician-Patient Relations; D018570:Risk Assessment / Q000379:methods; D055815:Young Adult