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Conservative or Cowboy – Does Risk Tolerance Impact Admission Rate?

March 22, 2024

Written by Amanda Mathews

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In this retrospective study of ED physicians in one state, researchers found statistically significant differences in admission rates among clinicians but little consistency in admission tendencies across multiple conditions. Clinicians with greater tolerance to risk (as a general attitude) had associated lower rates of admission when compared to projections.

Are you conservative or a cowboy?
This study had two major components that were later matched together to generate results. First, a physician risk tolerance survey was sent out to all practicing ED physicians in the state of Massachusetts. The survey instrument included 4 scales: the risk tolerance scale (RTS, 6 items), the stress from uncertainty scale (SUS, 13 items), the fear of malpractice scale (FMS, 6 items), and the need for cognitive closure scale (NCC, 15 items). Second, researchers used the state All Payer Claims Database to find ED visits with any sort of commercial insurance or Medicaid. They then linked survey results to ED visits over the study period by physician NPI. Providers who saw less than 30 patients in the study period or who did not complete the risk tolerance survey were excluded.

Ultimately, 392,676 ED visits completed by 691 physicians were included in the study. They considered all observation admits and transfers to higher levels of care as admissions for the purpose of data collection. Overall admission rates ranged from 36.3% (25th percentile) to 48.0% (75th percentile). Projected rates of admission were calculated for five common medical conditions: nonspecific chest pain, urinary tract infection, respiratory signs and symptoms, pneumonia (excluding TB), and syncope. The projected admission rates were compared to actual admission rates among providers and were statistically insignificant. This meant that across multiple conditions, a provider was just as likely to “over” admit than to “under” admit. Researchers did find that clinicians who expressed a greater tolerance to risk as a general attitude on the survey (not necessarily in medical terms) had lower rates of admission when compared to projections.

How will this change my practice?
While this study is certainly interesting, I don’t see it affecting my clinical practice. I think risk tolerance is only a component of my final disposition decision and not a particularly large component. This study shows that there is a great deal of provider variability in admission rates for certain conditions which mirrors what I have seen in clinical practice. The clinical presentation, reliability of patient, social support, access to follow up, and clinical gestalt play a larger role in my ultimate decision of whether to admit or discharge.

Clinician Risk Tolerance and Rates of Admission From the Emergency Department. JAMA Netw Open. 2024 Feb 5;7(2):e2356189. doi: 10.1001/jamanetworkopen.2023.56189.

What are your thoughts?