Key points Do emergency department physicians rely on the information found in the patient’s documented reason for visit section before a physician sees the patient? Findings In this cross-sectional study among 108,019 patients with congestive heart failure (CHF) who presented to the emergency department with difficulty breathing, physicians were less likely to test these patients for pulmonary embolism (PE) when the reason for the patient’s visit mentioned congestive heart failure (CHF). However, there was no association between the mention of CHF and the final diagnosis of acute PE. Meaning that physicians evaluated patients for pulmonary embolism (PE) less when the patient’s reason for visit section mentioned congestive heart failure (CHF), consistent with an anchoring bias that led to a delay in study and diagnosis of pulmonary embolism (PE). |
Introduction
Cognitive biases are hypothesized to influence physicians’ decision making, but large-scale evidence consistent with their influence is limited. One such bias is anchoring bias , or the focus on a single piece of information , often initial, when making clinical decisions without sufficiently adjusting to subsequent information.
Aim
To examine whether physicians were less likely to evaluate patients with congestive heart failure (CHF) who presented to the emergency department (ED) with shortness of breath (SOB) for pulmonary embolism (PE) when the reason for visit section of the patient, documented in triage before doctors see the patient, mentioned congestive heart failure (CHF).
Design, environment and participants
In this cross-sectional study of national Veterans Affairs data from 2011 to 2018, CHF patients presenting with SOB in Veterans Affairs emergency departments (EDs) were included in the analysis. The analyzes were carried out from July 2019 to January 2023.
Exposure
The reason for the patient’s visit section, documented in triage before physicians see the patient, mentions CHF.
Main results and measures
Primary outcomes were PE testing (D-dimer, contrast-enhanced chest CT, ventilation/perfusion scan, lower extremity ultrasonography), time to PE testing (among those screened for PE), B-type natriuretic peptide (BNP), acute PE diagnosed in the ED, and acute PE ultimately diagnosed (within 30 days of ED visit).
Results
The present sample included 108,019 patients (mean [SD] age, 71.9 [10.8] years; 2.5% women) with CHF presenting with SOB, 4.1% of whom mentioned CHF in the reason section. patient visit information for triage documentation.
Overall, 13.2% of patients underwent PE testing, on average within 76 minutes, 71.4% received BNP testing, 0.23% received an in-service diagnosis of acute PE emergency department and 1.1% ultimately received a diagnosis of acute PE.
In adjusted analyses, mention of CHF was associated with a 4.6 percentage point (pp) (95% CI, −5.7 to −3.5 pp) reduction in PE testing, 15.5 minutes longer (95% CI, 5.7-25.3 minutes) for EP testing, and 6.9 pp (95% CI, 4.3-9.4 pp) plus BNP testing.
Mention of CHF was associated with a 0.15 pp lower probability (95% CI, −0.23 to −0.08 pp) of PE diagnosis in the ED.
Conclusions and relevance
In this cross-sectional study among CHF patients presenting with SOB, physicians were less likely to test for pulmonary embolism (PE) when the reason for the patient’s visit that was documented before seeing the patient mentioned congestive heart failure (CHF).
Clinicians may rely on such initial information in their decision making, which in this case was associated with delayed workup and diagnosis of pulmonary embolism (PE).
