Emergency department patients who are treated by physicians with a high propensity to admit those they see in the hospital are more likely to be discharged after only a short stay, suggesting possible unnecessary admission, whereas they are not less likely to die, new research suggests. suggests.
The findings suggest that differences in physicians' skills or risk aversion may come into play when they make admissions decisions, said Dr. Dan Ly, assistant professor of medicine in the division of general internal medicine and health services research at the David Geffen School of Medicine. at UCLA.
“Doctors, like professionals in other fields, differ in their abilities and decisions, which impacts the amount of care you might receive, including, in this case, your likelihood of being hospitalized said Ly, co-author of the paper. with Stephen Coussens, health economist and senior data scientist at Abett, a data management company based in Washington state. “Some doctors may order more tests and hospitalize more of their patients, but that doesn't seem to translate into better health. »
The results will be published in the peer-reviewed journal JAMA Internal Medicine.
While previous studies have shown wide variation in emergency department physicians' likelihood of admitting a patient to the hospital, there is little evidence if and how this affects patient outcomes.
Using Veterans Affairs electronic health records from January 2011 to December 2019, researchers compared doctors practicing in the same emergency department. Their cross-sectional study collected data on 2,100 physicians in 105 emergency departments across the United States, including more than 2.1 million patient visits. They focused on patients presenting to the emergency room with chest pain, shortness of breath or abdominal pain.
Approximately 41% of visits led to hospitalization, with 19% of these patients discharged within 24 hours. The variation in admission rates varied considerably. For example, patients who consulted highly accepted doctors (those from the 90sth percentile) were almost twice as likely to be admitted as patients treated by low-admit physicians (those in the top 10th percentile), even though their underlying health status did not differ. Overall, approximately 2.5% of patients died within 30 days. The researchers found no relationship between a doctor's admission rate and their patients' 30-day mortality rate. This lack of relationship was also true for mortality at 7 days, 14 days, 90 days and one year.
The findings suggest that physician differences in admission rates depend less on the patient's underlying health condition than on variation in physician decision-making, the researchers write. Furthermore, these additional hospitalizations from high-admission physicians led neither to short-term protection against serious outcomes nor to a reduction in patients' risk of death up to a year later. And patients who were treated by doctors with low admitting propensity spent less time after their emergency room visit in the hospital, suggesting that low-propensity doctors were not simply postponing a necessary hospitalization in the future, they write.
Limitations of the study include the possibility that some potential clinical confounders were not captured in electronic health records; the way researchers used to measure patients' health before the emergency room visit, called the Elixhauser Comorbidity Index score, does not measure the severity of a person's presenting condition; variations in physician characteristics, such as medical training, could not be controlled; findings are specific to the VA, whose patients are largely male and whose emergency department staff is comprised of physicians more trained in non-emergency medicine, so the findings may not be applicable to others institutions; and other factors besides the physician also play a role in varying admission rates.
Although more research is needed to fully understand these differences in admission rates, “our study is able to better account for differences between patients and make concrete comparisons between physicians to demonstrate true differences.” in the practice models of emergency physicians and to show that these differences are not. “does not translate into better health outcomes for patients,” Ly said.
The study was funded in part by the Veterans Affairs Health Systems Research Center for the Study of Implementation of Health Care Innovation and Locally Initiated Project. (LIP 65-175)
Article: “Variation in emergency department physician admission practices and subsequent mortality,” doi: 10.1001/jamainternmed.2024.6925
