Association of Clinical Characteristics With Variation in Emergency Physician Preferences for Patients

Abstract

IMPORTANCE Much of the wide variation in health care has been associated with practice variation among physicians. Physicians choosing to see patients with more (or fewer) care needs could also produce variations in care observed across physicians. OBJECTIVE To quantify emergency physician preferences by measuring nonrandom variations in patients they choose to see. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study used a large, detailed clinical data set from an electronic health record system of a single academic hospital. The data set included all emergency department (ED) encounters of adult patients from

Association Between Emergency Physician Length of Stay Rankings and Patient Characteristics

“…Our prior investigation found that patients seen at the end of the shift are younger with fewer comorbidities, lower acuity, and more differentiated chief complaints than those seen at the start of the shift. 18 Our result that LOS is shorter at the end of shift, together with this previous finding, suggests that LOS could be measurably shaped by strategic patient selection. These findings indicate that LOS may be an unreliable metric for comparing emergency physician performance within a practice.…”

“…Our finding that there is variation in patient characteristics that cannot be modified by physicians across LOS quartiles demonstrates that LOS is associated with the types of patients seen, in addition to differences in physician practice patterns. Our prior investigation found that patients seen at the end of the shift are younger with fewer comorbidities, lower acuity, and more differentiated chief complaints than those seen at the start of the shift 18 . Our result that LOS is shorter at the end of shift, together with this previous finding, suggests that LOS could be measurably shaped by strategic patient selection.…”

“…Difference in LOS by Shift Order. Prior investigation demonstrated that physicians see younger patients with fewer comorbidities and lower acuity at the end of the shift; 18 thus, we additionally compared the LOS by the order in which patients were seen during a shift to examine the association between LOS and in-shift order. Figure 3 compares the LOS across shift order groups and shows that patients seen at the end of shift had LOS that was 36.3 minutes (15.5%) shorter than those seen at the start of the shift.…”

“…As a secondary outcome, we evaluated the association between LOS and the order in which patients were seen over the course of a shift. Prior investigation demonstrated that physicians see younger patients with fewer comorbidities and lower acuity at the end of the shift; 18 thus, an association between LOS and patients’ in‐shift order could additionally suggest that LOS could be measurably shaped through strategic patient selection (i.e., select patients with likely shorter LOS to reduce sign out to the incoming provider at the end of shift). Finally, we quantified the effect of variation in the characteristics of patients seen by different physicians (e.g., individual physician association with lower patient age) on relative LOS rankings within a practice group.…”

Analysis of Consistency in Emergency Department Physician Variation in Propensity for Admission Across Patient Sociodemographic Groups

“…Thus, observed patient characteristics vary minimally across ED physicians within the same hospital on average, although this balance may not hold in all EDs or within an ED shift. 18 In this study, we used this natural randomness to isolate physician-level variation in admission rates that was unrelated to variation in patient factors and thus mostly reflective of physician decision-making. 17 …”