Does What Happens in the ED Stay in the ED? The Effects of Emergency Department Physician Workload on Post-ED Care Use

Abstract

Problem definition: We study the effects of emergency department (ED) physician workload on healthcare system utilization after the patient leaves the ED. Further, we explore the mediating effects of care intensity in the ED on post-ED care use. Academic/practical relevance: ED crowding has been a pressing concern in healthcare systems in the United States and other developed countries. As such, many researchers have studied its effects on outcomes within the ED. In contrast, we present novel results regarding the impacts of ED crowding on system performance outside the ED—specifically, on post-ED care utilization. Methodology: We utilize a data set assembled from more than four years of microdata from a large U.S. hospital and exhaustive billing data in an integrated health system. We use count models and instrumental variable analyses to answer the proposed research questions. Results: We find that there is an increasing concave relationship between ED physician workload and post-ED care use. When ED workload increases from its fifth percentile to the median, the number of post-discharge care events (i.e., medical services) for patients who are discharged home from the ED increases by 5%, and it is stable afterward. Further, we identify physician test-ordering behavior as a mechanism for this effect; when the physician is busier, she responds by ordering more tests for less severe patients. We document that this “extra” testing generates “extra” post-ED care utilization for these patients. Managerial implications: This paper contributes new insights on how physician and patient behaviors under ED crowding impact a previously unstudied system performance measure: post-ED care utilization. Our findings suggest that prior studies estimating the cost of ED crowding underestimate the true effect, as they do not consider the “extra” post-ED care utilization.

Association between advanced image ordered in the emergency department on subsequent imaging for abdominal pain patients

“…Our results also showed a nonsignificant trend toward higher post-ED utilization of imaging among patients who were not imaged at times of higher ED crowding and physician workload. These 12 and suggest that when evaluating the effects of operational stress on ED decision making, downstream outcomes must be taken into account.…”

How does workload affect test ordering behavior of physicians? An empirical investigation

“…In contrast, Soltani et al. (2019) find that more tests are ordered when physician workload increases in the emergency department (ED), where they consider the number of tests as a mediator for the effect of physician workload on post‐ED care use. Our work contributes to this question by providing evidence from a novel outpatient setting where the service is completed after a test order.…”

“…Soltani et al. (2019) state that, when workload is high at the ED, physicians order more tests for less severe patients (patients who will be discharged), as the net effect of different mechanisms, including trying to reduce temporary workload, or physicians becoming more risk averse with increasing load. We propose rushing and diagnosis deferral as the drivers of the increase in the likelihood of test ordering in response to higher workload.…”

“…Soltani et al. 2019; Tan & Netessine, 2014), as opposed to system level (Batt & Terwiesch, 2017; Kc & Terwiesch, 2009; Kuntz et al., 2015), and thus are able to attribute the observed effects to individual decisions.…”

Understanding the perceived role of electronic health records and workflow fragmentation on clinician documentation burden in emergency departments

“…In the last decade, studies examining ED clinician workflows and workload in the context of EHR use largely have been conducted outside the United States. 25–28 Concurrently, US-based research has predominately focused on the quantification of ED work using direct observation methods 9 , 10 , 13 , 14 , 29–32 and retrospective data analyses, 33–36 and on the use of surveys to assess ED clinician sentiment. 30 , 34 Qualitative research on ED clinician EHR use has examined overall satisfaction, the effect of EHR usability and policy on clinical workflows, 12 , 37 and their perceptions of EHR clinical documentation 10 , 11 ; however, these studies exclusively highlight physician experiences.…”