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emergency medicine, uncertainty: emergency medicine, uncertaintyUncertainty is the driving force of the emergency department—it drives frightened patients to the ED to seek help and makes emergency physicians seek answers to puzzling diagnoses. Yet, payers and governments are hesitant to accept the reality of this uncertainty because the search for solutions can increase health care costs. A measurement of uncertainty called the U-Scale, under development by researchers at the Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia, may give emergency physicians and payers important clues about why patients come to the ED, go home unsure about their health status, and then return to the ED. Kristin Rising, MD, the director of acute care transition and an associate professor of emergency medicine at Jefferson, has focused her work on the patients' perspective about their needs when they returned to the emergency department. “The primary theme that has come up has been this ongoing fear and uncertainty that patients experience related to having symptoms,” she said. “It's scary and uncomfortable for many, and they don't know what they indicate. Do I have a new horrible disease and I'm going to die tomorrow? They don't know how to treat the symptoms or what they mean.” Dr. Rising said patients wonder why they have symptoms, so they come to a place where they can get answers, and this has been an underappreciated problem. “We need some way to tangibly measure this, and down the line measure their uncertainties better,” she said. Samuel G. Campbell, MB, BCh, a professor of emergency medicine at Dalhousie University in Halifax, Nova Scotia, Canada, said uncertainty is not limited to patients. Emergency physicians are often called upon to make decisions about patients based on inadequate knowledge, like one case where the “perfect storm” of uncertainty deferred the diagnosis for 24 hours of a diabetic patient on dialysis who suffered a seizure. (Acad Emerg Med 2007;14[8]:743; http://bit.ly/2JOXqrE.) The day after the seizure, the patient was seen by two emergency physicians, a cardiologist, and a neurologist. She was found to have been on warfarin for previous deep vein thrombosis a day after she was referred to the ED. A neurology consultant suspected spinal epidural hematoma, and an MRI showed a fracture at T12 with spinal compression. She was admitted to neurology with traumatic paraplegia. Dr. Campbell and his colleagues said error-producing conditions can result from uncertainty and the need to find an answer quickly can interfere with EPs' ability to diagnose a patient correctly. Dr. Campbell said this case was a classic example where a number of error-producing conditions interacted to produce a missed or delayed diagnosis. “I think it goes into this whole notion of uncertainty to a large degree. Emergency medicine is defined by decisions that people make with inadequate knowledge,” he said. The Price of Uncertainty Dr. Rising and her colleagues, in validating the U-Scale, identified domains of uncertainty related to new or ongoing symptoms. (J Health Psychol 2018. doi: 10.1177/1359105317752827. [Epub ahead of print]; http://bit.ly/2JVU7iw.) These symptoms involved recent ED patients who took part in group concept mapping. Patients were guided through brainstorming, sorting, and refining a set of ideas dealing with questions such as “When experiencing symptoms, people might choose to go to the emergency department when they feel uncertain about...?” The authors noted that their findings suggest that “uncertainty as measured by the U-Scale is only partially related to the state of anxiety and neuroticism, and thus, we are measuring something unique in the patient health care experience.” They said they hope to refine the scale to make it applicable to a variety of populations. Marianna D. LaNoue, PhD, an author of the study, said they want to test the scale in a more suburban setting to make sure they are capturing the full scope of the uncertainty. “The central hypothesis of the work is that the patients are not there because they know they have an acute problem but because they don't know what the right thing to do is,” she said. It is that uncertainty that some payers are seeking to control. The Centers for Medicare and Medicaid Services, for example, have set certain penalties for hospitals with patients who return for admission with 30 days at a high rate. Anthem, the nation's largest health insurance company, started to deny payment in 2015 for emergency department visits that the company decided were not truly emergencies. Its policy started in Kentucky, and has spread across several states. The company took a step back, however, when physicians, medical societies, and patients protested in February. Physicians admitted that some patients sought care in the emergency department unnecessarily, but that there is an equal risk that patients will avoid the emergency department when they need it because they fear the cost of an unreimbursed visit. A primary reason for both actions is uncertainty.

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