Elsevier

Resuscitation

Volume 162, May 2021, Pages 43-46
Resuscitation

Short paper
Age-related cognitive bias in in-hospital cardiac arrest

https://doi.org/10.1016/j.resuscitation.2021.01.016Get rights and content

Abstract

Aims

Cognitive bias has been recognized as a potential source of medical error as it may affect clinical decision making. In this study, we explored how cognitive bias, specifically left-digit bias, may affect patient outcomes in in-hospital cardiac arrest.

Methods

Using the Get With The Guidelines® – Resuscitation registry, we included adult patients with an in-hospital cardiac arrest from 2011 to 2019. The primary outcome was survival to hospital discharge. Secondary outcomes included return of spontaneous circulation, favorable neurological outcome, and duration of resuscitation. Using a regression discontinuity design, we explored whether there was a sudden change in survival at the age threshold of 80 years which would indicate left-digit bias. Additional analyses were performed at age thresholds of 60, 70, and 90 years.

Results

A total of 26,784 patients were included for the primary analysis. The overall survival was 22% in this cohort. There was no discontinuity of survival below and above the age of 80 years (risk difference, 0.47%; 95%CI, −1.61% to 2.56%). Similar results were estimated for the secondary outcomes and for the age thresholds of 60, 70, and 90 years. The results were consistent in sensitivity analyses.

Conclusions

There was no indication that cognitive bias based on age affected outcomes in in-hospital cardiac arrest in these data.

Introduction

Cognitive bias refers to systematic errors in reasoning including mental shortcuts (heuristics) that has been recognized as a potential source of medical error as it may affect clinical decision making.1 A recent study published in the New England Journal of Medicine explored this topic and found that patients with acute myocardial infarction who were admitted in the 2 weeks after their 80th birthday were significantly less likely to undergo coronary artery bypass grafting and had higher mortality compared to those admitted in the 2 weeks before their 80th birthday, suggesting the occurrence of cognitive bias, specifically left-digit bias.2 Left-digit bias refers to the concept of making decisions based only on the left digit, e.g. treating a 79-year old as “in their 70s” and a 80-year old as “in their 80s”. No study has explored whether left-digit bias exist in treatment of patients with an in-hospital cardiac arrest. Cognitive biases might be particularly prevalent in very acute conditions such as in-hospital cardiac arrest where decision-making is often rapid and based on limited information.

In this study, we utilized a regression discontinuity design to compare outcomes from in-hospital cardiac arrest in patients below and above specific age thresholds. The study was conducted to provide new insight into how cognitive bias may affect patient outcomes in in-hospital cardiac arrest.

Section snippets

Study design and data source

This was an observational study using data from the Get With The Guidelines®-Resuscitation (GWTG-R) registry. The GWTG-R is a prospective, quality-improvement registry of in-hospital cardiac arrest in the United States, sponsored by the American Heart Association. The registry has been described in detail elsewhere.3, 4, 5 Cardiac arrest is defined as a loss of pulse requiring chest compressions, defibrillation or both, with a hospital-wide or unit-based emergency response by acute care

Patient characteristics

There were 26,784 patients with an in-hospital cardiac arrest within three years below and above the age of 80 years (Fig. S1 in the Supplementary Content). Of these, 14,261 (53%) patients were between the age 77–80 years and 12,523 (47%) patients were between the age 80–83 years. Patient, event, and hospital characteristics are provided in Table S1 in the Supplementary Content.

Discontinuity threshold at age 80 years

The overall survival was 22% in patients with an in-hospital cardiac arrest at the age of 77–83 years. In the

Discussion

The presence of cognitive biases in decision-making was first described in the 1970s by Amos Tversky and Daniel Kahneman13 and popularized by Kahneman's 2011 book “Thinking, Fast and Slow”14. Although studies have explored cognitive biases in medical decision-making1, these studies have primarily focused on case-vignettes15, 16 and few have directly assessed patient-centered outcomes2, 17, 18. A specific type of cognitive bias is known as left-digit bias. The underlying assumption is that

Get With The Guidelines® – Resuscitation Investigators

Besides the author Ari Moskowitz, M.D., members of the Get With The Guidelines®-Resuscitation Adult Research Task Force include: Anne Grossestreuer PhD; Dana Edelson; MD MS; Joseph Ornato MD; Mary Ann Peberdy MD; Matthew Churpek MD MPH PhD; Michael Kurz MD MS-HES; Monique Anderson Starks MD MHS; Paul Chan MD MSc; Saket Girotra MBBS SM; Sarah Perman MD MSCE; and Zachary Goldberger MD MS.

Conflicts of interest and sources of funding

There are no disclosures. There was no specific funding for this study.

Authors’ contribution

Mathias J. Holmberg and Lars W. Andersen were responsible for the data acquisition, performed the statistical analyses, and drafted the manuscript. All authors contributed to the design of the study, interpreted the results, and critically revised the manuscript. All authors approved the final manuscript as submitted and agrees to be accountable for all aspects of the submitted work.

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1

The members of the Get With The Guidelines-Resuscitation Adult Research Task Force are listed at the end of the article.

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