"Sick" or "not-sick": Accuracy of System 1 diagnostic reasoning for the prediction of disposition and acuity in patients presenting to an academic ED

Jeffrey Wiswell, Kenyon Tsao, Fernanda Bellolio, Erik P. Hess, Daniel Cabrera

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21 Citations (Scopus)

Abstract

Objective System 1 decision-making is fast, resource economic, and intuitive (eg, "your gut feeling") and System 2 is slow, resource intensive, and analytic (eg, "hypothetico-deductive"). We evaluated the performance of disposition and acuity prediction by emergency physicians (EPs) using a System 1 decision-making process. Methods We conducted a prospective observational study of attending EPs and emergency medicine residents. Physicians were provided patient demographics, chief complaint, and vital sign data and made two assessments on initial presentation: (1) likely disposition (discharge vs admission) and (2) "sick" vs "not-sick". A patient was adjudicated as sick if he/she had a disease process that was potentially life or limb threatening based on pre-defined operational, financial, or educationally derived criteria. Results We obtained 266 observations in 178 different patients. Physicians predicted patient disposition with the following performance: sensitivity 87.7% (95% CI 81.4-92.1), specificity 65.0% (95% CI 56.1-72.9), LR+ 2.51 (95% CI 1.95-3.22), LR - 0.19 (95% CI 0.12-0.30). For the sick vs not-sick assessment, providers had the following performance: sensitivity 66.2% (95% CI 55.1-75.8), specificity 88.4% (95% CI 83.0-92.2), LR + 5.69 (95% CI 3.72-8.69), LR - 0.38 (95% CI 0.28-0.53). Conclusion EPs are able to accurately predict the disposition of ED patients using system 1 diagnostic reasoning based on minimal available information. However, the prognostic accuracy of acuity prediction was limited.

Original languageEnglish (US)
Pages (from-to)1448-1452
Number of pages5
JournalAmerican Journal of Emergency Medicine
Volume31
Issue number10
DOIs
StatePublished - Oct 2013

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Patient Acuity
Physicians
Emergencies
Decision Making
Vital Signs
Emergency Medicine
Observational Studies
Emotions
Extremities
Economics
Demography
Prospective Studies

ASJC Scopus subject areas

  • Emergency Medicine

Cite this

"Sick" or "not-sick" : Accuracy of System 1 diagnostic reasoning for the prediction of disposition and acuity in patients presenting to an academic ED. / Wiswell, Jeffrey; Tsao, Kenyon; Bellolio, Fernanda; Hess, Erik P.; Cabrera, Daniel.

In: American Journal of Emergency Medicine, Vol. 31, No. 10, 10.2013, p. 1448-1452.

Research output: Contribution to journalArticle

@article{cd62f973e9a54c70b7ad408bd4d0843b,
title = "{"}Sick{"} or {"}not-sick{"}: Accuracy of System 1 diagnostic reasoning for the prediction of disposition and acuity in patients presenting to an academic ED",
abstract = "Objective System 1 decision-making is fast, resource economic, and intuitive (eg, {"}your gut feeling{"}) and System 2 is slow, resource intensive, and analytic (eg, {"}hypothetico-deductive{"}). We evaluated the performance of disposition and acuity prediction by emergency physicians (EPs) using a System 1 decision-making process. Methods We conducted a prospective observational study of attending EPs and emergency medicine residents. Physicians were provided patient demographics, chief complaint, and vital sign data and made two assessments on initial presentation: (1) likely disposition (discharge vs admission) and (2) {"}sick{"} vs {"}not-sick{"}. A patient was adjudicated as sick if he/she had a disease process that was potentially life or limb threatening based on pre-defined operational, financial, or educationally derived criteria. Results We obtained 266 observations in 178 different patients. Physicians predicted patient disposition with the following performance: sensitivity 87.7{\%} (95{\%} CI 81.4-92.1), specificity 65.0{\%} (95{\%} CI 56.1-72.9), LR+ 2.51 (95{\%} CI 1.95-3.22), LR - 0.19 (95{\%} CI 0.12-0.30). For the sick vs not-sick assessment, providers had the following performance: sensitivity 66.2{\%} (95{\%} CI 55.1-75.8), specificity 88.4{\%} (95{\%} CI 83.0-92.2), LR + 5.69 (95{\%} CI 3.72-8.69), LR - 0.38 (95{\%} CI 0.28-0.53). Conclusion EPs are able to accurately predict the disposition of ED patients using system 1 diagnostic reasoning based on minimal available information. However, the prognostic accuracy of acuity prediction was limited.",
author = "Jeffrey Wiswell and Kenyon Tsao and Fernanda Bellolio and Hess, {Erik P.} and Daniel Cabrera",
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AU - Bellolio, Fernanda

AU - Hess, Erik P.

AU - Cabrera, Daniel

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N2 - Objective System 1 decision-making is fast, resource economic, and intuitive (eg, "your gut feeling") and System 2 is slow, resource intensive, and analytic (eg, "hypothetico-deductive"). We evaluated the performance of disposition and acuity prediction by emergency physicians (EPs) using a System 1 decision-making process. Methods We conducted a prospective observational study of attending EPs and emergency medicine residents. Physicians were provided patient demographics, chief complaint, and vital sign data and made two assessments on initial presentation: (1) likely disposition (discharge vs admission) and (2) "sick" vs "not-sick". A patient was adjudicated as sick if he/she had a disease process that was potentially life or limb threatening based on pre-defined operational, financial, or educationally derived criteria. Results We obtained 266 observations in 178 different patients. Physicians predicted patient disposition with the following performance: sensitivity 87.7% (95% CI 81.4-92.1), specificity 65.0% (95% CI 56.1-72.9), LR+ 2.51 (95% CI 1.95-3.22), LR - 0.19 (95% CI 0.12-0.30). For the sick vs not-sick assessment, providers had the following performance: sensitivity 66.2% (95% CI 55.1-75.8), specificity 88.4% (95% CI 83.0-92.2), LR + 5.69 (95% CI 3.72-8.69), LR - 0.38 (95% CI 0.28-0.53). Conclusion EPs are able to accurately predict the disposition of ED patients using system 1 diagnostic reasoning based on minimal available information. However, the prognostic accuracy of acuity prediction was limited.

AB - Objective System 1 decision-making is fast, resource economic, and intuitive (eg, "your gut feeling") and System 2 is slow, resource intensive, and analytic (eg, "hypothetico-deductive"). We evaluated the performance of disposition and acuity prediction by emergency physicians (EPs) using a System 1 decision-making process. Methods We conducted a prospective observational study of attending EPs and emergency medicine residents. Physicians were provided patient demographics, chief complaint, and vital sign data and made two assessments on initial presentation: (1) likely disposition (discharge vs admission) and (2) "sick" vs "not-sick". A patient was adjudicated as sick if he/she had a disease process that was potentially life or limb threatening based on pre-defined operational, financial, or educationally derived criteria. Results We obtained 266 observations in 178 different patients. Physicians predicted patient disposition with the following performance: sensitivity 87.7% (95% CI 81.4-92.1), specificity 65.0% (95% CI 56.1-72.9), LR+ 2.51 (95% CI 1.95-3.22), LR - 0.19 (95% CI 0.12-0.30). For the sick vs not-sick assessment, providers had the following performance: sensitivity 66.2% (95% CI 55.1-75.8), specificity 88.4% (95% CI 83.0-92.2), LR + 5.69 (95% CI 3.72-8.69), LR - 0.38 (95% CI 0.28-0.53). Conclusion EPs are able to accurately predict the disposition of ED patients using system 1 diagnostic reasoning based on minimal available information. However, the prognostic accuracy of acuity prediction was limited.

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