Variation in hospital admission rates between a tertiary care and two freestanding emergency departments

Higher Emergency Physician Chest Pain Hospitalization Rates Do Not Lead to Improved Patient Outcomes

BACKGROUND

Wide variation exists for hospital admission rates for the evaluation of possible acute coronary syndrome, but there are limited data on physician-level variation. Our aim is to describe physicians' rates of admission for suspected acute coronary syndrome and associated 30-day major adverse events.

METHODS

We conducted a retrospective analysis of adult emergency department chest pain encounters from January 2016 to December 2017 across 15 community emergency departments within an integrated health system in Southern California. The unit of analysis was the Emergency physician. The primary outcome was the proportion of patients admitted/observed in the hospital. Secondary analysis described the 30-day incidence of death or acute myocardial infarction.

RESULTS

Thirty-eight thousand seven hundred seventy-eight patients encounters were included among 327 managing physicians. The median number of encounters per physician was 123 (interquartile range, 82-157) with an overall admission/observation rate of 14.0%. Wide variation in individual physician admission rates were observed (unadjusted, 1.5%-68.9%) and persisted after case-mix adjustments (adjusted, 5.5%-27.8%). More clinical experience was associated with a higher likelihood of hospital care. There was no difference in 30-day death or acute myocardial infarction between high- and low-admitting physician quartiles (unadjusted, 1.70% versus 0.82% and adjusted, 1.33% versus 1.29%).

CONCLUSIONS

Wide variation persists in physician-level admission rates for emergency department chest pain evaluation, even in a well-integrated health system. There was no associated benefit in 30-day death or acute myocardial infarction for patients evaluated by high-admitting physicians. This suggests an additional opportunity to investigate the safe reduction of physician-level variation in the use of hospital care.

Decision fatigue in the Emergency Department: How does emergency physician decision making change over an eight-hour shift?

INTRODUCTION

We examined emergency physician disposition decisions and computed tomography (CT) ordering as markers of decision fatigue over an eight-hour shift.

METHODS

Administrative database analysis of patients presenting to an academic, tertiary care, emergency department (ED) over two years. Patients were grouped by the hour of the shift that they were initially assessed by an emergency physician. For each hour, we evaluated the proportions of patients who had CT head, chest, or abdomen, consultations, and consultations not resulting in admission. For patients discharged without consultation, we evaluated return visits within 72 h and ED length-of-stay (LOS). Statistical significance was assessed using random effects regression accounting for clustering by physician.

RESULTS

We analyzed 87,752 patients and there were no important differences in consultations, consultations not resulting in admission, or return visits in relation to the hour of shift the patient was seen. Rates of CT head and abdomen and ED LOS decreased as the shift progressed. From the first to the last hour, CT head ordering decreased from 15.8% to 12.2% (OR 0.73, 95% CI 0.66-0.80, p < 0.0001), CT abdomen ordering decreased from 9.6% to 7.6% (OR 0.72, 95% CI 0.64-0.80, p < 0.0001), and ED LOS decreased from 5.5 h to 4.9 h (relative difference 0.83, 95% CI 0.81-0.85, p < 0.0001).

CONCLUSIONS

Emergency physician decisions about patient disposition did not change throughout the shift. The rates of CT head and abdomen and ED LOS decreased as the shift progressed. We did not find evidence of decision fatigue among emergency physicians over an eight-hour shift.

Same provider, different location: Variation in patient satisfaction scores between freestanding and hospital-based emergency departments

BACKGROUND

Patient satisfaction scores have become quality benchmarks for hospitals, are publicly reported, and are often tied to financial incentives. We determined whether patient satisfaction scores for individual emergency medicine providers varied according to the clinical setting.

METHODS

We obtained patient satisfaction survey results from January 1, 2018 to December 31, 2018 for patients treated at 6 freestanding (FED) and 11 hospital-based emergency departments (HBED). Differences in mean score by ED facility were tested for significance. Mean score differences with 95% confidence intervals are presented. Univariate and multivariable logistic regression analysis was conducted to predict the odds of receiving different scores by type of ED facility and adjusted for patient and provider demographics and ED length of stay.

RESULTS

Sixty-six providers with 3743 total surveys were analyzed: FED (n = 1974) and HBED (n = 1769). Overall satisfaction scores were higher for FED compared to HBED surveys 1.13 [95% CI, 1.0-1.3]. In multivariable logistic regression, we found patients seen at the FEDs were 42% more likely to rate providers courtesy as "very good" compared to patients seen at a HBED [OR: 1.42, 95% CI (0.94-2.15)]. Similarly, patients from FEDs showed increased likelihood to rate providers as "very good" for keeping patients informed about treatment [OR: 1.70, 95% CI (1.21-2.39)], took time to listen to patients [OR: 1.66, 95% CI (0.72-1.60)] and concerned for patient's comfort [OR: 1.54, 95% CI (1.12-2.12)].

CONCLUSION

Individual providers, who practice at both types of facilities, consistently received higher satisfaction ratings from patients at FEDs compared to HBEDs.

Freestanding Emergency Department Entry and Market-level Spending on Emergency Care

Background

Freestanding emergency departments (FrEDs) could reduce wait times in overcrowded emergency departments (EDs), but they might also increase usage and overall spending for emergency care. We investigate the relationship between the number of FrEDs entering a local market and overall spending on emergency care.

Methods

We accessed data from Arizona, Florida, North Carolina, and Texas in Blue Cross Blue Shield Axis; a limited data set of deidentified insurance data claims that we linked to Public Use Microdata Area (PUMA) data from the American Community Survey; and lists of licensed FrEDs from state agencies. Regression analysis was used to estimate the association between changes in the number of FrEDs in 495 PUMAs and total spending on emergency care, out‐of‐pocket spending, utilization, and price per visit from January 2013 to December 2017. Final estimates came from a PUMA‐level fixed‐effects model, with controls for state, quarter, and PUMA‐level demographics.

Results

Entry of an additional FrED in a PUMA was associated with a 3.6 percentage point (pp; CI = 2.4 to 4.9) increase in emergency provider reimbursement per insured beneficiary in Texas, Florida, and North Carolina. There was no change in spending (2.5 pp; CI = −8.2 to 3.1) associated with a FrED's entry in Arizona. Entry of an additional FrED was associated with a 0.18 (CI = 0.12 to 0.23) increase in the number of emergency care visits per 100 enrollees in Texas, Florida, and Arizona. In contrast, entry of another FrED was not associated with a change in utilization (−0.03; CI =  −0.09 to 0.02) in North Carolina. Estimated out‐of‐pocket payments for emergency care increased 3.6 pp (CI = 2.5 to 4.8) with the entry of a FrED in Texas, Florida, and Arizona, but declined by 15.3 pp (CI = −26.8 to −3.7) in North Carolina.

Conclusions

Rather than functioning as substitutes for hospital‐based EDs, FrEDs have increased local market spending on emergency care in three of four states’ markets where they have entered. State policy makers and researchers should carefully track spending and utilization of emergency care as FrEDs disseminate to better understand their potential health benefits and cost implications for patients.

A Comparison of Care Delivered in Hospital-based and Freestanding Emergency Departments

OBJECTIVE

We compare case mix, hospitalization rates, length of stay (LOS), and resource use in independent freestanding emergency departments (FSEDs) and hospital-based emergency departments (H-EDs).

METHODS

Data from 74 FSEDs (2013-2015) in Texas and Colorado were compared to H-ED data from the 2013-2014 National Hospital Ambulatory Medical Care Survey. In the unrestricted sample, large differences in visit characteristics (e.g., payer and case mix) were found between patients that use FSEDs compared to H-EDs. Therefore, we restricted our analysis to patients commonly treated in both settings (<65 years, privately insured, nonambulance) and used inverse propensity score weighting (IPW) to balance the two settings on observable patient characteristics. We then compared ED LOS and as well as hospital admission rates and resource utilization rates in the IPW-weighted samples.

RESULTS

Before balancing, FSEDs saw more young adults (age 25-44) and fewer older adults (age 45-64) than H-EDs. FSED patients had fewer comorbidities, more injuries and respiratory infections, and fewer diagnoses of chest or abdominal pain. In balanced samples, LOS for FSED visits was 46% shorter (60 minutes) than H-ED patients. Hospital admission rates were 37% lower overall (95% confidence interval = -51% to -23%) in FSEDs and varied considerably by primary discharge diagnosis. X-ray and electrocardiogram use was significantly lower at FSEDs while others measures of resource utilization were similar (ultrasound, computed tomography scans, and laboratory tests).

CONCLUSION

In this sample of FSEDs, a greater proportion of younger patients with fewer comorbidities and more injuries and respiratory system diseases were evaluated, and almost all patients had private health insurance. When restricted to < 65 years, privately insured, and nonambulance patients in both samples, LOS was considerably shorter and hospital admission rates lower at FSEDs, as well as the use of some diagnostic testing. This study is limited as diagnoses codes may not fully capture severity and patients who perceived greater need of hospital admission may have chosen a H-ED over FSEDs.