Emergency physicians' risk attitudes in acute decompensated heart failure patients

Objectives: Despite the existence of various clinical prediction rules, no data exist defining what frequency of death or serious nonfatal outcomes comprises a realistic "low-risk" group for clinicians. This exploratory study sought to identify emergency physicians' (EPs) definition of low-risk acute decompensated heart failure (ADHF) emergency department (ED) patients.

Methods: Surveys were mailed to full-time physicians (n = 88) in a multihospital EP group in southwestern Pennsylvania between December 2004 and February 2005. Participation was voluntary, and each EP was asked to define low risk (low risk of all-cause 30-day death and low risk of either hospital death or other serious medical complications) and choose a risk threshold at which they might consider outpatient management for those with ADHF. A range of choices was offered (<0.5, <1, <2, <3, <4, and <5%), and demographic data were collected.

Results: The response rate was 80%. Physicians defined low risk both for all-cause 30-day death and for hospital death or other serious complications, at <1% (38.8 and 40.3%, respectively). The decision threshold to consider outpatient therapy was <0.5% risk both for all-cause 30-day death (44.6%) and for hospital death or serious medical complications (44.4%).

Conclusions: Emergency physicians in this exploratory study define low-risk ADHF patients as having less than a 1% risk of 30-day death or inpatient death or complications. They state a desire to have and use an ADHF clinical prediction rule that can identify low-risk ADHF patients who have less than a 0.5% risk of 30-day death or inpatient death or complications.