Both physicians and patients overestimate the risk of heart attack or death for possible acute coronary syndrome (ACS) as well as the potential benefit of hospital admission for possible ACS. A survey of patient and physician communication and risk assessment, along with an editorial, were published online last week in Annals of Emergency Medicine.
"Even immediately after the patient and doctor discuss the reasons for hospital admission, it turns out we're disagreeing about those reasons two-thirds of the time," said lead study author David Newman, MD, of the Icahn School of Medicine at Mount Sinai in New York, N.Y. "In many ways, it seems almost like we're ships passing in the night. To us, what this suggests is that patient-doctor communication is largely ineffective, and that a costly and potentially burdensome decision--admission to the hospital--is being made without patients understanding 'why', and thus without being able to participate in that decision."
Of patients who were admitted to the hospital from the emergency department with possible ACS, 65 percent reported discussing their risk of myocardial infarction (heart attack) with their physicians, while physicians reported such discussions occurred with only 46 percent of patients. Following discussion with their physicians, patients' assessment of their risk of heart attack remained the same or increased.
There was a huge disparity between patients and physicians about their relative risk of heart attack at home (versus the hospital). Patients assessed mortality risk from heart attack at 80 percent if they were sent home, but only 10 percent if they were admitted to the hospital. Physicians estimated those risks at 15 percent if sent home and 10 percent if admitted to the hospital.
An editorial accompanying the study speculates that numerous concerns, including fears of liability, guide decision-making in patients with possible ACS.
"What is concerning here is that the actual average risk of death or heart attack within 30 days was less than 2 percent," said the author of the editorial, Erik P. Hess, MD, MSc, of the Mayo Clinic in Rochester, Minn. "Risk communication in the ER is far from straightforward and physicians and patients may have very different ideas of what constitutes 'low risk.' That said, we have to do a better job of telling our patients the facts without inflating either their hopes or their fears."
Misperceptions of risks and benefits of a wide variety of medical screenings and interventions have been a focus of study in recent years as the health care system struggles to ratchet down costs and improve outcomes. Emergency physicians have long advocated for the development of clinical practice guidelines as a way to decrease testing and admissions that are ordered, in part, as a hedge against being sued.
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