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Heart Disease and Stroke

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ER doctors often overestimate the need for critical care for patients with acute congestive heart failure

Congestive heart failure (CHF) is a leading cause of hospitalization for elderly patients. In the absence of specific guidelines for triaging CHF patients, up to 47 percent of hospitalized patients with CHF go to intensive care units (ICUs). However, doctors tend to drastically overestimate the need for ICU care for these patients, according to a study that was supported in part by the Agency for Healthcare Research and Quality (HS06274).

Researchers led by Wally R. Smith, M.D., of Virginia Commonwealth University, prospectively studied triage decisions of emergency department (ED) doctors caring for ED patients with acute CHF at an urban university hospital, a community hospital, and a VA hospital. They reviewed the medical charts of these patients to determine whether each patient died or developed severe complications within 4 days of ED triage and asked physicians about the probability of this outcome.

Overall, 4.2 percent of triaged CHF patients died or developed severe complications. A calibration curve that stratified doctors' judgments by deciles of the highest probability of death or serious complications showed that they consistently overestimated this probability. For example, of the 74 patients whom ED doctors judged to have the highest probability of these problems, only 14 patients (19 percent) actually died or developed serious complications. Of the 19 patients that doctors judged to be in the next highest probability decile (81 to 90 percent), only two patients (11 percent) died or experienced severe complications.

Thus, doctors were only moderately proficient at discriminating which CHF patients would die or experience severe complications. This probably led to overuse of scarce ICU resources, since the higher a doctor's prediction of death or severe complications, the more likely the doctor was to send that patient to a more intense care setting. Patients admitted to an ICU received the highest average predicted probability (56 percent), followed by those admitted to a telemetry unit (34 percent), a regular hospital ward (30 percent), or sent home (18 percent).

More details are in "Prognostic judgments and triage decisions for patients with acute congestive heart failure," by Dr. Smith, Roy M. Poses, M.D., Donna K. McClish, Ph.D., and others, in the May 2002 Chest 121, pp. 1610-1617.

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