Impact of Physician Scorecards on Emergency Department Resource Use, Quality, and Efficiency

Abstract

BACKGROUND AND OBJECTIVES: Variability in practice patterns and resource use in the emergency department (ED) can affect costs without affecting outcomes. ED quality measures have not included resource use in relation to ED outcomes and efficiency. Our objectives were to develop a tool for comprehensive physician feedback on practice patterns relative to peers and to study its impact on resource use, quality, and efficiency. METHODS:We evaluated condition-specific resource use (laboratory tests; imaging; antibiotics, intravenous fluids, and ondansetron; admission) by physicians at 2 tertiary pediatric EDs for 4 common conditions (fever, head injury, respiratory illness, gastroenteritis). Resources used, ED length of stay (efficiency measure), and 72-hour return to ED (return rate [RR]) (balancing measure) were reported on scorecards with boxplots showing physicians their practice relative to peers. Quarterly scorecards were distributed for baseline (preintervention, July 2009-August 2010) and postintervention (September 2010-December 2011). Preintervention, postintervention, and trend analyses were performed. RESULTS:In 51 450 patient visits (24 834 preintervention, 26 616 postintervention) seen by 96 physicians, we observed reduced postintervention use of abdominal and pelvic and head computed tomography scans, chest radiographs, intravenous antibiotics, and ondansetron (P , .01 for all). Hospital admissions decreased from 7.4% to 6.7% (P = .002), length of stay from 112 to 108 minutes (P , .001), and RR from 2.2% to 2.0%. Trends for use of laboratory tests and intravenous antibiotics showed significant reduction (P , .001 and P , .05, respectively); admission trends increased, and trends for use of computed tomography scans and plain abdominal radiographs showed no change.CONCLUSIONS: Physician feedback on practice patterns relative to peers results in reduction in resource use for several common ED conditions without adversely affecting ED efficiency or quality of care.There has been considerable focus on overall resource use and cost of care in our nation's emergency departments (EDs), particularly for nonemergent conditions that often make up a large share of the case mix in the typical ED. Additionally, wide variation in practice and resource use that cannot be explained by patient-related factors has been demonstrated in both adults and children, including emergency medicine patients. [1][2][3][4][5][6][7][8][9][10][11][12] Excessive use of resources in health care has not been found to improve quality or outcomes, but it does affect cost. 11,[13][14][15][16] The recent Choosing Wisely initiative encourages every specialty to consider reducing use of tests and procedures that are often unnecessary and sometimes can be harmful. 17 Traditional ED quality measures have included measures of timeliness such

Return Visit Admissions May Not Indicate Quality of Emergency Department Care for Children

“…The most common diagnoses previously reported at ED return visits—fever, respiratory infections, and gastroenteritis—are all self‐limited acute medical conditions commonly treated in outpatient as well as ED settings and thus appropriate for a trial of outpatient management. Our findings are also consistent with pediatric studies that have found poor reliability of ED return visits as a performance measure in its lack of correlation with other ED process measures such as rate of radiographic study utilization and physician treatment time …”

“…Children represent a unique population to consider given differences in the clinical conditions for which they are commonly cared for in the ED and differences in how pediatric care is delivered. Previous work has challenged the construct validity of return visits as a measure of ED care quality for children—these include chart review studies that find the majority of ED return visits and ED return admissions are due to progression of illness or patient's noncompliance with care rather than poor quality of initial ED care and secondary data analyses demonstrating the poor reliability of ED return visits as a performance measure compared with other ED process measures . Other studies have challenged the common practice of tracking only same‐hospital ED return visits—these studies show that 12% to 32% of 72‐hour return visits among adults and all‐ages populations do not occur at the same hospital as the index visit …”

The impact of pediatric emergency department crowding on patient and health care system outcomes: a multicentre cohort study

“…For example, variability in emergency department clin icians' adherence to available evidence-based clinical guidelines, risk tolerance, clinical decision-making and efficiency may affect both emergency department crowding and patient outcomes. [27][28][29] Another variable of interest, which we could not access for this study, was inpatient hospital occupancy rates at the time of emergency department index arrival. The impact of not including these variables as potential confounders is difficult to estimate, as no prior studies have reported on their association with emergency department length of stay and clinical outcome measures.…”

Think A-Head Campaign of Image Gently: Shared Decision-Making in Pediatric Head Trauma

“…This could be achieved using a provider scorecard and a peer-learning feedback system. 21 Practices and institutional consensus of relevant stakeholders should determine whether decision rules are needed and which rules are the most appropriate. Auditing both impact and adherence to rules should also be part of this process.…”