Physician Risk Perception and Testing Behaviors for Children With Fever
Ashley L Marchese1, Andrew M Fine, Jason A Levy
1From the Division of Emergency Medicine, Boston Children's Hospital, Boston, MA.
Insights
Physician risk perception, including risk tolerance, stress from uncertainty, and malpractice fear, did not influence decisions to order blood or imaging tests for febrile children in the emergency department.
Area of Science:
- Pediatric Emergency Medicine
- Clinical Decision-Making
- Health Psychology
Background:
- Physician risk perception and tolerance may influence diagnostic test ordering.
- Understanding these factors is crucial for optimizing emergency department (ED) care for febrile children.
Purpose of the Study:
- To investigate the association between physician risk perception and the utilization of blood or imaging tests in children presenting with fever to the ED.
- To explore how different facets of risk perception (tolerance, stress from uncertainty, malpractice fear) relate to diagnostic testing patterns.
Main Methods:
- Retrospective, cross-sectional study at Boston Children's Hospital ED involving children (6 months-18 years) with fever from 2014-2019.
- Assessed physician risk perception using the Risk Tolerance Scale (RTS), Stress From Uncertainty Scale (SUS), and Malpractice Fear Scale (MFS).
- Used mixed-effects logistic regression to analyze the association between risk perception scores and primary (blood/imaging tests) and secondary outcomes.
Main Results:
- Analyzed 12,527 encounters with 55 physicians; blood/imaging test utilization varied widely (median 48%).
- No significant association was found between RTS, SUS, or MFS scores and the decision to order blood or imaging tests.
- No significant associations were observed for secondary outcomes, with a weak link between SUS and specialist consultation.
Conclusions:
- Physician risk perception, encompassing tolerance, uncertainty, and malpractice concerns, does not appear to be a significant determinant of diagnostic test ordering for febrile children in the ED.
- These findings suggest that factors other than individual physician risk perception drive testing practices in this clinical context.
Objectives:
Risk tolerance and risk perceptions may impact clinicians' decisions to obtain diagnostic tests. We sought to determine whether physician risk perception was associated with the decision to obtain blood or imaging tests among children who present to the emergency department with fever.
Methods:
We conducted a retrospective, cross-sectional study in the Boston Children's Hospital emergency department. We included children aged 6 months to 18 years from May 1, 2014 to April 30, 2019, with fever. Our primary outcome was diagnostic testing: obtaining a blood and/or imaging test. We assessed risk perception using 3 scales: the Risk Tolerance Scale (RTS), Stress From Uncertainty Scale (SUS), and Malpractice Fear Scale (MFS). A z score was assigned to each physician for each scale. Mixed-effects logistic regression assessed the association between physician risk perception and blood or imaging testing. We also examined the relationship between each risk perception scale and several secondary outcomes: blood testing, urine testing, diagnostic imaging, specialist consultation, hospitalization, and revisit within 72 hours.
Results:
The response rate was 55/56 (98%). We analyzed 12,527 encounters. Blood/imaging testing varied between physicians (median, 48%; interquartile range, 41%-53%; range, 30%-71%). Risk Tolerance Scale responses were not associated with blood/imaging testing (odds ratio [OR], 1.03 per SD of increased risk perception; 95% confidence interval [CI], 0.95-1.13). Stress From Uncertainty Scale responses were not associated with blood/imaging testing (OR, 1.04 per SD; 95% CI, 0.95-1.14). Malpractice Fear Scale responses were not associated with blood/imaging testing (OR, 1.00 per SD; 95% CI, 0.91-1.09). There was no significant association between RTS, MFS, or SUS and any secondary outcome, except that there was a weak association between SUS and specialist consultation (OR, 1.12; 95% CI, 1.00-1.24).
Conclusions:
Across 55 pediatric emergency physicians with variable testing practices, there was no association between risk perception and blood/imaging testing in febrile children.
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