Physician Practice Variation in the Pediatric Emergency Department and Its Impact on Resource Use and Quality of Care

Jain, Shabnam; Elon, Lisa; Johnson, Brent A.; Frank, Gary; DeGuzman, Michael A.

doi:10.1097/pec.0b013e3181fe9108

Cited by 44 publications

(34 citation statements)

References 43 publications

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“…We have previously shown wide variation in physician use of common resources in our ED; higher resource use was associated with greater LOS but did not reduce return to ED. 4 In a recent study,…”

Section: Figurementioning

confidence: 99%

“…We have previously documented large variation in practice in the ED even after adjusting for patient (eg, acuity, age) and temporal factors. 4 We used this persistent variation in practice to highlight individual physician performance relative to the range of practice of their peers. We did this by creating a comprehensive and balanced scorecard showing physicians their resource use and ED quality metrics, relative to their peers, for 4 common ED conditions.…”

Section: Setting and Scorecard Developmentmentioning

confidence: 99%

“…18,19 Efforts to streamline resource use by standardizing practice through evidence-based guidelines have been ongoing, but significant degrees of variation in practice remain. 4,5,19 Current ED quality measures do not include measures of efficient use of resources or how they correlate with ED outcomes. In recently proposed indicators of quality in pediatric EDs, none of the 62 evaluated unnecessary tests.…”

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confidence: 99%

“…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.…”

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confidence: 99%

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

et al. 2015

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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

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Section: Figurementioning

confidence: 99%

Section: Setting and Scorecard Developmentmentioning

confidence: 99%

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confidence: 99%

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confidence: 99%

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

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“…6,7 Several reports examining pediatric CT scanning for particular indications, including head trauma and appendicitis, suggest that variability across hospitals exists and is in part due to differences in institutional practice, availability of CT, and lack of protocol-driven decision-making on when to image. [8][9][10][11][12] An assessment of the variability in the rate of CT scanning inclusive of all body regions and indications is useful to evaluate if differences in CT imaging rates are due to institutional factors, such as case-mix or hospital volume. Furthermore, identifying the contribution of patient disposition (emergency department [ED] treatand-release, inpatient, or outpatient) may help identify specific patient cohorts undergoing higher rates of CT scanning or groups of prescribers that may be overusing CT scans.…”

Section: What This Study Addsmentioning

confidence: 99%

Variation in Utilization of Computed Tomography Imaging at Tertiary Pediatric Hospitals

et al. 2015

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BACKGROUND: Recent efforts have focused on reducing computed tomography (CT) imaging in children. Although published reports show variability in CT scanning for specific indications, an assessment of the effects of institutional factors (case-mix or hospital volume) on the rate of CT scanning for any indication is necessary to better understand variability across pediatric hospitals. METHODS:Data from 2009 to 2013 on inpatient, observation, and emergency department (ED) encounters were extracted from the Pediatric Health Information System. Chronological trends and institutional variability in CT scan rates were examined by using negative binomial regression models. Case-mix was adjusted by using All Patient Refined Diagnosis Related Groups and severity level.RESULTS: Thirty hospitals were included. There were 12 531 184 patient encounters and 701 644 CT scans resulting in a mean of 56 scans per 1000 encounters (range: 26-108). The most common scan types were head (60.1%) and abdomen/pelvis (19.9%). There was an inverse relationship between the CT scan rate and hospital volume (P = .002) and a direct relationship between the CT scan rates for inpatient/observation and ED encounters (P , .001). The rate of CT imaging decreased from 69.2 to 49.6 scans per 1000 encounters during the study period (P , .001). CONCLUSIONS:The overall use of CT imaging is decreasing, and significant variability remains in CT use across tertiary pediatric hospitals. Hospital volume and institutional-level practices account for a significant portion of the variability. This finding suggests an opportunity for standardization through multi-institutional quality improvement projects to reduce CT imaging. WHAT'S KNOWN ON THIS SUBJECT:Given the efforts to decrease the use of ionizing radiation in pediatric patients, there is significant variability in head computed tomography (CT) scan use in pediatric emergency departments for minor head trauma. WHAT THIS STUDY ADDS:This study characterized variability in CT scan rates for all body regions in emergency department, observation, and inpatient encounters across 30 tertiary pediatric hospitals. Two-fold variation remained after case-mix adjustment, with higher volume hospitals having lower rates of CT scanning.

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Evaluation of Version 4 of the Emergency Severity Index in US Emergency Departments for the Rate of Mistriage

et al. 2023

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ImportanceAccurate emergency department (ED) triage is essential to prioritize the most critically ill patients and distribute resources appropriately. The most used triage system in the US is the Emergency Severity Index (ESI).ObjectivesTo derive and validate an algorithm to assess the rate of mistriage and to identify characteristics associated with mistriage.Design, Setting, and ParticipantsThis retrospective cohort study created operational definitions for each ESI level that use ED visit electronic health record data to classify encounters as undertriaged, overtriaged, or correctly triaged. These definitions were applied to a retrospective cohort to assess variation in triage accuracy by facility and patient characteristics in 21 EDs within the Kaiser Permanente Northern California (KPNC) health care system. All ED encounters by patients 18 years and older between January 1, 2016, and December 31, 2020, were assessed for eligibility. Encounters with missing ESI or incomplete ED time variables and patients who left against medical advice or without being seen were excluded. Data were analyzed between January 1, 2021, and November 30, 2022.ExposuresAssigned ESI level.Main Outcomes and MeasuresRate of undertriage and overtriage by assigned ESI level based on a mistriage algorithm and patient and visit characteristics associated with undertriage and overtriage.ResultsA total of 5 315 176 ED encounters were included. The mean (SD) patient age was 52 (21) years; 44.3% of patients were men and 55.7% were women. In terms of race and ethnicity, 11.1% of participants were Asian, 15.1% were Black, 21.4% were Hispanic, 44.0% were non-Hispanic White, and 8.5% were of other (includes American Indian or Alaska Native, Native Hawaiian or other Pacific Islander, and multiple races or ethnicities), unknown, or missing race or ethnicity. Mistriage occurred in 1 713 260 encounters (32.2%), of which 176 131 (3.3%) were undertriaged and 1 537 129 (28.9%) were overtriaged. The sensitivity of ESI to identify a patient with high-acuity illness (correctly assigning ESI I or II among patients who had a life-stabilizing intervention) was 65.9%. In adjusted analyses, Black patients had a 4.6% (95% CI, 4.3%-4.9%) greater relative risk of overtriage and an 18.5% (95% CI, 16.9%-20.0%) greater relative risk of undertriage compared with White patients, while Black male patients had a 9.9% (95% CI, 9.8%-10.0%) greater relative risk of overtriage and a 41.0% (95% CI, 40.0%-41.9%) greater relative risk of undertriage compared with White female patients. High relative risk of undertriage was found among patients taking high-risk medications (30.3% [95% CI, 28.3%-32.4%]) and those with a greater comorbidity burden (22.4% [95% CI, 20.1%-24.4%]) and recent intensive care unit utilization (36.7% [95% CI, 30.5%-41.4%]).Conclusions and RelevanceIn this retrospective cohort study of over 5 million ED encounters, mistriage with ESI was common. Quality improvement should focus on limiting critical undertriage, optimizing resource allocation by patient need, and promoting equity.

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Physician Practice Variation in the Pediatric Emergency Department and Its Impact on Resource Use and Quality of Care

Abstract: Significant variation exists in physician use of common ED resources. Higher resource use was associated with increased LOS but did not reduce return to ED. Practice variation such as this may represent an opportunity to improve health care quality and decrease costs.

Cited by 44 publications

References 43 publications

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

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

Variation in Utilization of Computed Tomography Imaging at Tertiary Pediatric Hospitals

Evaluation of Version 4 of the Emergency Severity Index in US Emergency Departments for the Rate of Mistriage

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