Lit Matters 2: Can Anchoring Bias Mislead in CHF and PE Diagnosis?

Anchoring bias can narrow emergency department workups before the clinician ever sees the patient. In dyspnea with known CHF, triage framing that names heart failure was associated with less pulmonary embolism testing and more BNP ordering, a useful prompt to consciously reopen the differential.

Anchoring Bias in Dyspnea and CHF

• Triage framing effect: A chief complaint that explicitly mentioned CHF shifted downstream decision-making in shortness-of-breath visits, suggesting the triage summary can act as an early anchor before bedside assessment begins.
• Pulmonary embolism workup: Among CHF patients with dyspnea, PE testing was ordered less often when CHF appeared in the pre-physician record, despite PE remaining an important competing diagnosis.
• BNP ordering pattern: BNP was obtained more frequently when CHF was named up front, a concrete sign that the initial frame pushed clinicians toward a heart-failure-first pathway.
• Missed versus delayed PE: ED PE diagnoses were lower in the CHF-mentioned group, while 30-day PE diagnoses were nearly unchanged, raising the possibility of delayed recognition more than true absence of disease. We get into that distinction in the episode.
• Study scale and limits: This was a VA cross-sectional review of 108,019 visits across 104 hospitals, but unmeasured bedside findings like edema or hemoptysis still limit any claim that triage wording alone caused bias.
• Bedside cognitive reset: The practical move is not to distrust triage but to deliberately rebuild the differential in dyspnea, especially when an obvious label like CHF arrives before your own exam.