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

项目概要： 个体医生的决策是决定医疗保健变化程度的重要因素 急诊科（艾德）为研究 决策的变化。了解风险规避在外行决策中的重要性，我们 假设风险厌恶对急诊医生（EP）有更大的影响力 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认知闭合需要（NFC），相关的特质，可能有一个 对ED的决策产生深远的影响。总之，这些特征转化为一定程度的临床 焦虑或强迫症这种特征在EP中的分布尚不清楚， 这种性格特征对病人有利或有害。很可能一个特别焦虑或强迫性的EP 容易受到过度测试（委员会的错误），而这种过度测试会导致潜在的有害后果。 下游成果。然而，在艾德环境中，对于某些临床条件， 艾德设置可能通过最大限度地减少漏诊和选择潜在的关键诊断来提供保护。 对于大多数艾德状况，定义较高或较低的测试是否更好，或者是否更好，这是未知且至关重要的 一系列的测试与更好的结果相关。迫切需要确定这些特征 与急诊室的检查强度和入院决定有关。 对于设计干预措施，教育EP了解其内在的风险厌恶或设定对风险的期望至关重要。 关键临床条件下的理想实践强度水平。然而，即使风险厌恶和NFC的流行 在EP之间-以及它们与决策之间的关系-在很大程度上是未知的。 拟议的研究将结合联合收割机的调查数据，从EP-以及从先进的实践提供商， 他们在提供紧急护理方面的作用越来越大-整个马萨诸塞州的利用率数据来自一个所有的 付款人索赔数据库（我们将通过结合Medicare索赔数据和马萨诸塞州所有 支付人索赔数据库），以实现三个关键目标。首先，我们将测量 马萨诸塞州EP/APP人群的风险厌恶和NFC。然后我们将确定 提供者风险规避/NFC分数和实践强度（实验室测试，成像 研究，和住院的频率）的关键临床条件在ED。最后，我们将研究 实践强度和患者伤害之间的关系，利用患者随机 分配给EP。除了揭示医疗决策的一个基本上未探索的领域，我们的 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的供应商做出更标准的管理决策， 管理风险规避和可能导致的认知偏差之间的界面。

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.