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

项目总结： 个别医生的决策是卫生保健差异程度的重要决定因素 急诊科(ED)为研究高血压的决定因素提供了一个理想的环境。 决策过程中的变化。了解风险规避在外行决策中的基本重要性，我们 假设风险厌恶有可能对急诊医生(EP)产生更大的影响 因为紧急护理的高风险和不确定性。 这项研究将集中在风险厌恶和对认知闭合(NFC)的需求，这些相关特征可能具有 对教育部门的决策产生深远的影响。加在一起，这些特征转化为一定程度的临床 EP中的焦虑或强迫症。这一特征在EP中的分布尚不清楚，也不清楚是否 这种个性特征对患者是有益的，也是有害的。很可能是一种特别焦虑或强迫性的EP 将容易受到过度测试(委托错误)的影响，并且这种过度测试会导致潜在的危害 下游结果。然而，在ED环境中，对于某些临床情况，在 ED设置可能会起到保护作用，因为它可以最大限度地减少漏诊和发现潜在的危重诊断。 对于大多数ED情况，定义更高或更低的测试是更好的，还是如果 一系列测试与更好的结果相关。迫切需要确定这些特征是否 与教育部的工作强度和录取决定有关。描绘这种关系的是 对于设计干预措施以教育EPs了解他们内在的风险厌恶或设定对 关键临床条件的理想练习强度水平。然而，即使是避险和NFC的盛行 在EP中--以及它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的调查数据-以及给定的高级实践提供商的调查数据 他们在提供紧急护理方面的作用越来越大-使用来自ALL的利用率数据在整个马萨诸塞州 付款人索赔数据库(我们将结合Medicare索赔数据和Massachusetts All构建该数据库 Payer Claims数据库)来实现三个关键目标。首先，我们将测量患病率和分布情况 马萨诸塞州EPs/app人群的风险厌恶和NFC。然后我们将确定这一关系 提供者的风险厌恶/NFC分数和练习强度(实验室测试次数、成像 研究和入院频率)了解急诊科的关键临床情况。最后，我们将检查 练习强度与患者伤害的关系，利用患者是随机的事实 已分配给EP。除了揭示一个在很大程度上未被探索的医疗决策领域，我们的 研究结果将作为制定和实施行为干预的基础 引导具有不同风险承受能力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接口。

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.