Admission decisions in emergency department chest pain patients at low risk for myocardial infarction: Patient versus physician preferences

Study objective: Patient involvement in medical decisionmaking is accepted as an ethical and a legal imperative. Medical decisions are based in part on individuals' knowledge and acceptance of risk of adverse consequences. It is unclear whether actions taken to protect against low risk of poor outcome reflect patient or physician preferences. We sought to test the hypothesis that emergency department chest pain patients presented with a hypothetical situation involving a low risk of myocardial infarction are more willing than ED physicians to accept the risk associated with discharge from the hospital. Methods: We prospectively surveyed 89 ED patients with chest pain and a cohort of physicians in the ED who had been presented a hypothetical case in which the risk of AMI was quoted as 5% and the risk of death or disability if the patient was discharged was 1% and 2% if the patient was admitted. All the patients had presented to the ED with a chief complaint of chest pain; the 31 physicians, all residents, were approached at a teaching conference separate from their clinical duties. Results: Twenty-eight patients (31%), compared with 2 physicians (6%), chose discharge for the hypothetical patient with chest pain (25% difference; 95% confidence interval [CI], 6% to 41%). Forty-four patients (49%), compared with 30 physicians (97%), correctly identified the risks associated with admission and discharge (46% difference; 95% CI, 29% to 63%). Of the subjects who correctly identified the risks, 19 patients (43%) preferred discharge, compared with 1 physician (3%) (40% difference; 95% CI, 18% to 60%). Conclusion: ED patients with chest pain appear to be more likely than physicians to accept a small risk of poor outcome in a hypothetical circumstance. Many patients cannot identify the risks associated with their decision.