Individual emergency physician admission rates: predictably unpredictable

Abstract

Objective: We sought to determine the degree and possible causes of variability in admission practices among individual emergency physicians (EPs) at 1 emergency department (ED) using a Canadian Emergency Department Triage Acuity Scale (CTAS)-matched ED patient population. Methods: We distributed a survey measuring attitudes and demographics to all EPs (n = 30) at a large regional hospital. Hospital admissions data from 1 calendar year were matched to individual EP survey results. Emergency physicians were ranked as "lower," "average" or "higher" admitters and, using these categorical variables, the data set was analyzed for correlations and trends. Results: Overall, 97.0% of the EPs responded to the survey. Admissions by EPs ranged from 8.7% to 17.0%, (mean 12.52, standard deviation [SD] 2.21) of all patients seen. CTAS category-specific admission data demonstrated variability in the admission ranking of individual EPs. No EPs consistently performed at any 1 admission ranking across all CTAS categories. More years of emergency medicine experience was significantly correlated with higher admissions in the CTAS-2 ranking (r = 0.4, p < 0.05). Whether a physician worked full-time, part-time or as a locum was not associated with patterns of admission, nor was any particular postgraduate certification (e.g., CCFP, CCFP EM, FRCPC) or any of the surveyed attitudinal traits. Conclusion: Individual EPs' overall and CTAS-specific admissions varied substantially, and followed an approximately normal distribution curve. Emergency physicians with more years of experience had a statistically higher CTAS-2 admission rate; however, other variables, including postgraduate certification status, decision-related attitudes toward admission, and reported practices were not associated with admission proportions. Emergency physicians tend to have uniquely individual admission ranking profiles across all the CTAS categories.

Variation in readmission rates by emergency departments and emergency department providers caring for patients after discharge

“…After adjusting for patient and clinical characteristics, admission rates varied from 21% to 49% among physicians and from 27% to 41% among 3 facilities. Two other studies from single hospitals have found similar variation among providers . The reasons for the variation among ED providers presumably relate to subjective aspects of clinical assessment and the reluctance of providers to rely solely on objective scales, even when they are available .…”

“…Two other studies from single hospitals have found similar variation among providers . The reasons for the variation among ED providers presumably relate to subjective aspects of clinical assessment and the reluctance of providers to rely solely on objective scales, even when they are available . Variation in admission rates among different facilities may relate to clustering of providers with similar practice styles within facilities, lack of clinical guidelines for certain conditions, as well as differences among facilities in the socioeconomic status and access to primary care of their clientele .…”

Physician Variability in Management of Emergency Department Patients with Chest Pain

“…It is possible that with greater experience comes a greater appreciation for unanticipated outcomes, or that physicians are simply more likely to experience a lawsuit the longer they practice. Previous studies have been mixed in terms of the impact of physician experience on levels of testing and admission 10,36,37. Further work will be necessary to clarify the exact impact and role of experience, how it differs for different clinical conditions, and how it interacts with risk tolerance.…”

The Association Between Physician Empathy and Variation in Imaging Use

“…Interventions that target practice variation in diagnostic imaging could improve healthcare delivery and reduce health care costs, cancer risk due to exposure to ionizing radiation, and downstream effects of incidental findings . In particular, there is significant variation in emergency physician utilization of computed tomography (CT) imaging, but the underlying causes of this variation remain unclear . Previous studies have suggested that physician characteristics, such as differences in physician risk tolerance or perceived malpractice risk, may account for the variation in emergency department (ED) decision‐making …”