Can ED docs' uncertainty tolerance affect patient health/resource use
Research type
Research Study
Full title
Can Emergency Doctors’ Tolerance of Uncertainty Impact on Patient Outcomes and Resource Use? A Multi-Site, Multi-Level, Retrospective Cohort Study
IRAS ID
292830
Contact name
Rebecca Lawton
Contact email
Sponsor organisation
Bradford Teaching Hospitals Foundation Trust
Duration of Study in the UK
0 years, 9 months, 1 days
Research summary
Summary of Research
One essential skill of emergency doctors is to quickly, but safely, identify and satisfy treatment needs of individual patients, while managing patient flow. Importantly, this relies on deciding who needs treatment, and who may be diverted elsewhere – often a decision with risks. Optimal ED decision making in requires doctors to balance risks; a balance moderated by the degree to which doctors can tolerate uncertainty in their decisions.Research in other specialties show that doctors who dislike uncertainty make more risk-averse decisions, for example by ordering more diagnostic tests/referring more patients. These doctors may be likely to use more vital NHS resources which may be better directed elsewhere. One primary aim of this study is to assess whether uncertainty tolerance impacts resource use in emergency medicine too. Another is to assess whether uncertainty tolerance is associated with patient outcomes. This is because uncertainty tolerance may not be wholly positive; it may increase high-risk decision making which may incur patient harm, e.g. a patient may be inappropriately diverted.
In a retrospective cohort study, we will recruit A&E doctors in 5 emergency departments, before having them complete a questionnaire designed to assess uncertainty tolerance (+ other factors, e.g. burnout/demographics). Collaborators at each site will then identify recent patients our recruited doctors have assessed and extract anonymised data about the episodes, including patient demographics, whether the patient was admitted, what tests/treatments were ordered, patients' length of stay if admitted, and readmissions. Models will assess whether doctor-level uncertainty tolerance is associated with these patient health/resource use outcomes, adjusted for certain site-level (e.g. busyness), doctor-level (e.g. experience) and patient-level (e.g. comorbidity status) factors.
In an embedded study, we will also interview consenting doctors to get their views on what helps them cope with uncertainty, with the aim of informing a future intervention to help moderate uncertainty tolerance
Summary of Results
: Abstract Introduction Emergency departments face increasing strain, necessitating efficient resource management without compromising care. While higher uncertainty tolerance (UT) among medical staff has been linked to reduced resource use and improved wellbeing in various specialties, its impact in emergency settings is underexplored. This study aimed to develop a theory-based UT measure and associations with doctor-related factors (e.g. experience), patient outcomes (e.g. 30-day reattendance), and resource use (e.g. episode costs).
Methods
From May 2021 to February 2022, emergency doctors (Specialty Trainee 3 and above) from five Yorkshire (UK) departments completed an online questionnaire. This included a novel UT measure—an adapted Physicians' Reaction to Uncertainty scale collaboratively modified within our team according to Hillen et al.’s (2017) comprehensive UT model. The questionnaire also included wellbeing-related measures (e.g. Brief Resilience Scale) and assessed factors like doctors’ seniority. Patient encounters involving prespecified ‘uncertainty-inducing’ complaints (e.g. headache) were analysed. Multilevel regression explored associations between doctor-level factors, resource use, and patient outcomes.
Results
Thirty-nine doctors were matched with 384 patients. The UT measure demonstrated high reliability (Cronbach’s = 0.92) and higher UT was significantly associated with better psychological wellbeing, including greater resilience (Pearson’s r = 0.56; 95% CI = 0.30 to 0.74) and lower burnout (e.g. Cohen’s d = -2.98; -4.62 to -1.33; mean UT difference for ‘no’ vs. ‘moderate/high’ burnout). UT was not significantly associated with resource use (e.g. episode costs: β = -0.07; -0.32 to 0.18) or patient outcomes, including 30-day readmission (e.g. OR = 0.82; 0.28 to 2.35).
Conclusions
We developed a reliable UT measure for emergency medicine. While higher UT was linked to doctor wellbeing, its impact on resource use and patient outcomes remains unclear. Further measure validation and additional research, including intervention trials, are necessary to confirm these findings and explore the implications of UT in emergency practice.
What is already known on this topic
Emergency medicine demands rapid decision-making with limited information, where doctors’ tolerance for uncertainty may affect resource utilisation and clinical decisions.
What this study adds
We introduce a measure of uncertainty tolerance, showing significant associations with improved doctor wellbeing but inconclusive results for resource use and patient outcomes.
How this study might affect research, practice or policy Enhancing uncertainty tolerance could improve doctor wellbeing, suggesting potential benefits from integrating tolerance training in emergency departments. Further research is needed to replicate findings related to resource use and patient outcomes.REC name
East of Scotland Research Ethics Service REC 2
REC reference
21/ES/0030
Date of REC Opinion
2 Apr 2021
REC opinion
Further Information Favourable Opinion