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Methods
Four Norwegian casualty clinics were chosen for cooperation and collection of data, according to strategic sampling. The casualty clinics cover both rural, suburban and urban districts, and include both larger and smaller clinics. Data were collected prospectively from February to July 2012.
The analysed data consist of structured telephone interviews with 100 physicians (each physician interviewed only once) shortly after a consultation with a patient meeting the inclusion criteria. Registration of patients continued until 100 unique physicians with 100 corresponding patients had been included. All patients with "chest pain" or equivalent symptoms as their main symptom, independent of the probable cause of complaint, were registered by nurses at the four casualty clinics. Equivalent symptoms included "tightness in chest", "retrosternal pain" and "chest discomfort". Patients with symptoms clearly suggestive of mastitis were excluded. If a physician could not be reached by telephone, and interviewed, within 2 days after the consultation, he or she was excluded from participation, in order to reduce recall bias. The interviewer was a general practitioner with experience in out-of-hours work (author RAB).
The questionnaire used in the telephone interview was divided in to two parts, where the first part consisted of questions related to the patient they just had treated, including "level of response", diagnostic measures (use of ECG and laboratory analyses), severity of illness, appraisal of most probable cause of symptoms and choice of treatment and level of care.
The results from the first part of the questionnaire, and a more detailed description of the methods of the study, are described elsewhere in a recently published paper. Analyses showed that the study population (n = 100) did not differ from all registered chest pain patients (n = 832) in any of the variables stated, except mean age, the study patients were about 5 years younger.
Analyses from part two of the questionnaire are presented in this article. This part of the questionnaire focused on the individual physician's approach to diagnosing patients with chest pain, the physician's "tolerance of risk", and attitudes to hospital admission. Diagnostic approach was measured using a five-point Likert scale where the physicians graded the importance of different aspects of the diagnostic process.
"Tolerance of risk" was measured using the Pearson Risk Scale, and a new Tolerance of Risk Scale, developed for this study.
Pearson Risk Scale
The Pearson Risk Scale was developed for triage decisions in patients with chest pain. This scale consists of six items with questions answered along a six-point Likert scale from "strongly agree" to "strongly disagree" (Table 1). The scale divides physicians into one of three categories based on summation of the scores; high scorers ("risk-seeking") scored one standard deviation or more above the mean, middle-scorers scored midrange, and low scorers scored more than one standard deviation below the mean ("risk-avoiders").
Tolerance of Risk Scale
To develop the Tolerance of Risk Scale, we used the seven first items of a questionnaire from a previously published article (Ingram-questionnaire), slightly adapted to a Norwegian out-of-hours-setting. This questionnaire consists of statements where the physicians should select the appropriate level of agreement according to a five-point Likert scale from "agree strongly" to "disagree strongly". Furthermore, we used a similar approach to how the Pearson Risk Scale was constructed, dividing the physicians into one of three "risk groups", naming it the "Tolerance of Risk Scale".
The Pearson Risk Scale measures physician "risk attitudes" in general, while the newly developed Tolerance of Risk Scale specifically measures "risk attitudes" working in an out-of-hours-setting.
Attitudes to Hospital Admission
Attitudes to hospital admission were measured using 15 items from three dimensions (B - D) of the Ingram-questionnaire.
Statistics. IBM Statistical Package for the Social Sciences (IBM SPSS version 20) was used for statistical analyses. Standard univariate statistics were used to describe the material, including mean and median. Mann–Whitney U test was used for comparison between the items from the Ingram-questionnaire and the Pearson Risk Scale. For other comparisons Chi-Square tests were used. A P-value of < 0.05 was considered statistically significant.
Ethics. The study was given approval by the Regional Committee for Medical and Health Research Ethics (REC West) before inclusion started (Reference number 2010/1499-10).
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