Behaving Discretely - Scholars at Harvard - Harvard University

Nov 13, 2017 - diagnosing heart disease in the emergency department, a common task with life- or-death ...... Pierre, Fullerton, Heather J, et al. Heart disease ...
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Behaving Discretely Heuristic Thinking in the Emergency Department

(Job Market Paper) Stephen Coussens† November 13, 2017 Link to most recent version:

Abstract This paper explores the use of heuristics among highly-trained physicians diagnosing heart disease in the emergency department, a common task with lifeor-death consequences. Using data from a large private-payer claims database, I find compelling evidence of heuristic thinking in this setting: patients arriving in the emergency department just after their 40th birthday are roughly 10% more likely to be tested for and 20% more likely to be diagnosed with ischemic heart disease (IHD) than patients arriving just before this date, despite the fact that the incidence of heart disease increases smoothly with age. Moreover, I show that this shock to diagnostic intensity has meaningful implications for patient health, as it reduces the number of missed IHD diagnoses among patients arriving in the emergency department just after their 40th birthday, thereby preventing future heart attacks. I then develop a model that ties this behavior to an existing literature on representativeness heuristics, and discuss the implications of this class of heuristics for diagnostic decision-making. †

Harvard Kennedy School, 79 JFK St, Cambridge, MA, 02138. E-mail: coussen[email protected]. Website:

I am grateful to my advisors Brigitte Madrian, David Cutler, and Ziad Obermeyer for their support and guidance. I thank Daniel Shoag, Nathan Hendren, Katie Coffman, and John Beshears for their helpful conversations. I also thank my classmates and all participants in the Harvard Economics Department Labor Workshop, Labor Lunch, and the Harvard Medical School Health Economics Seminar for their helpful comments and suggestions.

Stephen Coussens

Behaving Discretely



Most economic models make the simplifying assumption that the decision-maker is able to precisely optimize choice using all available information, both continuous and discrete in nature. Yet there also exists a well-established literature in both economics and psychology demonstrating the important role of heuristic decision-making (and the biases it can generate) in a variety of contexts (Gilovich et al., 2002; Kahneman et al., 1982). Evidence in both experimental (List, 2003, 2004; Alevy et al., 2015) and non-experimental (Lacetera et al., 2012) settings indicates that the effects of "nonstandard decision-making" (DellaVigna, 2009) on market transactions tend to be concentrated among naive agents with limited experience making the decision at hand. This suggests that anomalous behavior may not have a meaningful impact in settings in which the decision-makers are highly trained or experienced. This paper provides evidence of an important environment in which this notion is violated. I explore the use of heuristics in a high-stakes setting in which the agents are highly trained professionals making familiar decisions. Specifically, I examine physician treatment patterns in the emergency department (ED) involving the diagnosis of ischemic heart disease (IHD), a common yet life-threatening condition. Given that age is a strong predictor of heart disease, the manner in which physicians incorporate this continuous attribute into their assessment of a patient’s risk for IHD is likely to meaningfully influence treatment decisions. If physicians employ a cognitive shortcut that discretizes age into coarse categories, patients falling on either side of a category boundary may receive substantially different treatment, despite being otherwise similar. Using private-payer health insurance claims for over 5 million ED visits in the U.S. between 2005 and 2013, I find evidence that emergency physicians use a heuristic that


Stephen Coussens

Behaving Discretely

classifies a subset of these patients as higher-risk