Measuring Patient Tolerance for Future Adverse Events in Low-Risk Emergency Department Chest Pain Patients - 23/07/14

Doi : 10.1016/j.annemergmed.2013.12.025

Jennifer C. Chen, MD, MPH ^a,^⁎ , Richelle J. Cooper, MD, MSHS ^b, Ana Lopez-O'Sullivan, MD ^b, David L. Schriger, MD, MPH ^b
^a Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA
^b UCLA Emergency Medicine Center, University of California, Los Angeles, CA

^∗Corresponding Author.

Abstract

Study objective

We assess emergency department (ED) patients' risk thresholds for preferring admission versus discharge when presenting with chest pain and determine how the method of information presentation affects patients' choices.

Methods

In this cross-sectional survey, we enrolled a convenience sample of lower-risk acute chest pain patients from an urban ED. We presented patients with a hypothetical value for the risk of adverse outcome that could be decreased by hospitalization and asked them to identify the risk threshold at which they preferred admission versus discharge. We randomized patients to a method of numeric presentation (natural frequency or percentage) and the initial risk presented (low or high) and followed each numeric assessment with an assessment based on visually depicted risks.

Results

We enrolled 246 patients and analyzed data on 234 with complete information. The geometric mean risk threshold with numeric presentation was 1 in 736 (1 in 233 with a percentage presentation; 1 in 2,425 with a natural frequency presentation) and 1 in 490 with a visual presentation. Fifty-nine percent of patients (137/234) chose the lowest or highest risk values offered. One hundred fourteen patients chose different thresholds for numeric and visual risk presentations. We observed strong anchoring effects; patients starting with the lowest risk chose a lower threshold than those starting with the highest risk possible and vice versa.

Conclusion

Using an expected utility model to measure patients' risk thresholds does not seem to work, either to find a stable risk preference within individuals or in groups. Further work in measurement of patients' risk tolerance or methods of shared decisionmaking not dependent on assessment of risk tolerance is needed.

Le texte complet de cet article est disponible en PDF.

Plan

Introduction

Background

Importance

Goals of This Investigation

Materials and Methods

Study Design and Setting

Selection of Participants

Data Collection and Processing

Outcome Measures

Primary Data Analysis

Results

Characteristics of Study Subjects

Limitations

Discussion

	Supervising editor: Robert L. Wears, MD, PhD
	Author contributions: All authors conceived the study and designed the trial. JCC and AL-O supervised the conduct of the trial and data collection. DLS analyzed the data, with assistance from JCC. JCC drafted the article. RJC, AL-O, and DLS contributed substantially to its revision. JCC takes responsibility for the paper as a whole.
	Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org/). The authors have stated that no such relationships exist.
	Please see page 128 for the Editor's Capsule Summary of this article.
	A JDXZF3V survey is available with each research article published on the Web at www.annemergmed.com.
	A podcast for this article is available at www.annemergmed.com.