Medical Uncertainty and Variation in Hospitalization Rates for Suspected AcuteIschemic Heart Disease. Executive Summary and Final Reports

摘要

The study was undertaken to test the 'uncertainty hypothesis', which holds thatvariations in rates of hospitalization or surgeries across small geographic areas reflects differences in physicians' decisionmaking when confronting uncertainty. A small-areas variation analysis of suspected acute ischemic heart disease (AIHD) admissions in Michigan was performed, and two demographically nearly identical towns differing by a factor of three in AIHD admission rates were selected. Medical records of all patients evaluated in the emergency departments of these hospitals for suspected AIHD in 1988 were retrospectively abstracted. Probabilities of AIHD were objectively estimated using the Acute Coronary Ischemia Time-Insensitive Instrument. Logistic regression of admission on patient characteristics, other illnesses, probability of AIHD, and community was performed on the abstracted patient chart data. No difference in admission decisions between the two hospitals was demonstrated. Nearly twice as many AIHD patients presented to the emergency department of the high-admitting hospital as to the low-admitting one. The authors conclude that at least for AIHD, area discharge rates do not reflect decision rates. Drawing inferences about physician decisionmaking from discharge datasets may lead to error.