Although intubation is a commonly discussed procedure in emergency medicine, the number of opportunities for emergency physicians to perform it is unknown. We determine the frequency of intubation ...performed by emergency physicians in a national emergency medicine group.
Using data from a national emergency medicine group (135 emergency departments EDs in 19 states, 2010 to 2016), we determined intubation incidence per physician, including intubations per year, intubations per 100 clinical hours, and intubations per 1,000 ED patient visits. We report medians and interquartile ranges (IQRs) for estimated intubation rates among emergency physicians working in general EDs (those treating mixed adult and pediatric populations).
We analyzed 53,904 intubations performed by 2,108 emergency physicians in general EDs (53,265 intubations) and pediatric EDs (639 intubations). Intubation incidence varied among general ED emergency physicians (median 10 intubations per year; IQR 5 to 17; minimum 0, maximum 109). Approximately 5% of emergency physicians did not perform any intubations in a given year. During the study, 24.1% of general ED emergency physicians performed fewer than 5 intubations per year (range 21.2% in 2010 to 25.7% in 2016). Emergency physicians working in general EDs performed a median of 0.7 intubations per 100 clinical hours (IQR 0.3 to 1.1) and 2.7 intubations per 1,000 ED patient visits (IQR 1.2 to 4.6).
These findings provide insights into the frequency with which emergency physicians perform intubations.
Managing emergency physicians is a complex task and has increasingly intensified with the recent consolidation of many emergency departments (EDs). Large‐scale physician groups are facing challenges ...in resource deployment and performance evaluation. To objectively evaluate physicians across facilities, we leverage big data from an emergency physician management network and propose data‐driven metrics using a large‐scale database consisting of 84 hospitals, 1,079 physicians, and 10,615,879 patient visits in 14 states over 600,000 clinical shifts from 2010 to 2014. To ensure physicians are fairly evaluated and compensated within diverse facilities, we propose an index system and use clustering to help identify factors which might impact physician performance. The proposed indices benchmark physicians from the perspectives of revenue potential, patient volume, patient complexity, and patient experience by controlling for exogenous factors at the facility level. We empirically show the volume and complexity indices are key elements of the revenue potential index, and use two‐stage least squares regression to relate volume and complexity and uncover their drivers. Revenue potential and patient experience are found to be positively correlated, which suggests productive physicians are often liked by their patients. Through implementing the proposed evaluation system, administrators can better manage and incentivize physicians and provide directions for performance improvement, while controlling for location idiosyncrasies. The proposed framework can also be adapted to non‐medical professional settings such as value chains, where employees often provide services in various profit‐ and cost‐centers.
We examine changes in emergency department (ED) visit acuity and care intensity for uninsured patients who gained Medicaid insurance in 2014 under the Patient Protection and Affordable Care Act. We ...use 2013-2015 longitudinal patient visit-level data from 30 EDs across 7 states from an emergency medicine group. We examine changes in ED use by previously uninsured Medicaid patients and patients remaining uninsured who were repeat ED users (≥1 visit before and after expansion) using a propensity-score weighted approach with statistical machine learning to estimate the weights. Compared with those remaining uninsured in nonexpansion states, newly covered Medicaid patients in expansion states showed a 29% relative increase in hospital admissions and 32% increase in admissions for nonambulatory care sensitive conditions with no increases in care intensity. Obtaining Medicaid insurance increased the relative proportion of ED visits requiring hospital admission suggesting increased outpatient access for low-acuity conditions previously addressed with ED care.
The fee-for-service funding model for US emergency department (ED) clinician groups is increasingly fragile. Traditional fee-for-service payment systems offer no financial incentives to improve ...quality, address population health, or make value-based clinical decisions. Fee-for-service also does not support maintaining ED capacity to handle peak demand periods. In fee-for-service, clinicians rely heavily on cross-subsidization, where high reimbursement from commercial payors offsets low reimbursement from government payors and the uninsured. Although fee-for-service survived decades of steady cuts in government reimbursement rates, it is increasingly strained because of visit volatility and the effects of the No Surprises Act, which is driving down commercial reimbursement. Financial pressures on ED clinician groups and higher hospital boarding and clinical workloads are increasing workforce attrition. Here, we propose an alternative model to address some of these fundamental issues: an all-payer-funded, voluntary global budget for ED clinician services. If designed and implemented effectively, the model could support robust clinician staffing over the long term, ensure stability in clinical workload, and potentially improve equity in payments. The model could also be combined with population health programs (eg, pre-ED and post-ED telehealth, frequent ED use programs, and other innovations), offering significant payer returns and addressing quality and value. A linked program could also change hospital incentives that contribute to boarding. Strategies exist to test and refine ED clinician global budgets through existing government programs in Maryland and potentially through state-level legislation as a precursor to broader adoption.
Reducing excessive opioid prescribing in emergency departments (ED) may prevent opioid addiction. We evaluated the largest personalized feedback and peer comparison intervention to date on emergency ...clinician opioid prescription rates in a national emergency clinician group.
This interrupted time series analysis of a quality improvement intervention included data from adults discharged from 102 EDs in 17 states from January 1, 2019, to July 31, 2021. From June 16, 2020, to November 30, 2020, site-level ED directors received emails on local opioid prescription rates. From December 1, 2020, to July 31, 2021, all clinicians were granted electronic dashboard access, which showed prescription rates compared with peers, and national ED leaders sent emails to high-prescribing clinicians and engaged in one-on-one conversations. The primary outcome was opioid prescriptions per 100 discharges.
The study included 5,328,288 ED discharges from 924 physicians and 472 advanced practice providers. Opioid prescription rates did not change meaningfully in the site-level director feedback period (mean difference = −0.3, 95% confidence interval CI −0.6 to −0.1). During the direct clinician feedback period, opioid prescription rates declined from 10.4 per 100 discharges to 8.4 per 100 discharges (mean difference = −2.0, 95% CI −2.4 to −1.5), a 19% relative reduction. Among prescribers in the highest initial quintile, opioid prescribing reduced by 35% among physicians and 41% among advanced practice providers in the direct feedback period.
We demonstrated a large, sustained reduction in opioid prescribing by emergency clinicians using direct, personalized feedback to clinicians and an electronic dashboard for peer comparison.
With the improvements in medical care and resultant increase in life expectancy of the intellectually disabled, it will become more common for healthcare providers to be confronted by ethical ...dilemmas in the care of this patient population. Many of the dilemmas will focus on what is in the best interest of patients who have never been able to express their wishes with regard to medical and end-of-life care and who should be empowered to exercise surrogate medical decision-making authority on their behalf. A case is presented that exemplifies the ethical and legal tensions surrounding surrogate medical decision making for acutely ill, never-competent, profoundly intellectually disabled patients.
We evaluate variability and construct validity in commercially generated patient-experience survey data in a large sample of US emergency departments (EDs).
We used Press Ganey patient-experience ...data from a national emergency medicine group from 2012 to 2015 across 42 facilities and 242 physicians. We estimated variability as month-to-month changes in percentile scores and through intraclass correlations. Construct validity was assessed with linear regression analysis for monthly facility- and physician-level percentile scores.
A total of 1,758 facility-months and 10,328 physician-months of data were included. Across facility-months, 40.8% had greater than 10 points of percentile change, 14.7% changed greater than 20 points, and 4.4% changed greater than 30. Across physician-months, 31.9% changed greater than 20 points, 21.5% changed greater than 30, and 13.6% changed greater than 40. Intraclass correlation estimates demonstrated similar variability; however, this was reduced as data were aggregated over fixed time increments. For facility-level construct validity, several facility factors predicted higher scores: teaching status; more older, male, and discharged patients without Medicaid insurance; lower patient volume; less requirement for physician night coverage; and shorter lengths of stay for discharged patients. For physician-level construct validity, younger physician age, participating in satisfaction training, increasing relative value units per visit, more commercially insured patients, higher computed tomography or magnetic resonance imaging use, working during less crowded times, and fewer night shifts predicted higher scores.
In this sample, both physician- and facility-level patient-experience data varied greatly month to month, with physician variability being considerably higher. Facility-level scores have greater construct validity than physician-level ones. Optimizing data gathering may reduce variability in ED patient-experience data and better inform decisionmaking, quality measurement, and pay for performance.
We examine the association between emergency physician characteristics and practice factors with the risk of being named in a malpractice claim.
We used malpractice claims along with provider, ...operational, and jurisdictional data from a national emergency medicine group (87 emergency departments EDs in 15 states from January 1, 2010, to June 30, 2014) to assess the relationship between individual physician and practice variables and being named in a malpractice claim. Individual and practice factors included years in practice, emergency medicine board certification, visit admission rate, relative value units generated per hour, total patients treated as attending physician of record, working at multiple facilities, working primarily overnight shifts, patient experience data percentile, and state malpractice environment. We assessed the relationship between emergency physician and practice variables and malpractice claims, using logistic regression.
Of 9,477,150 ED visits involving 1,029 emergency physicians, there were 98 malpractice claims against 90 physicians (9%). Increasing total number of years in practice (adjusted odds ratio 1.04; 95% confidence interval 1.02 to 1.06) and higher visit volume (adjusted odds ratio 1.09 per 1,000 visits; 95% confidence interval 1.05 to 1.12) were associated with being named in a malpractice claim. No other factors were associated with malpractice claims.
In this sample of emergency physicians, 1 in 11 were named in a malpractice claim during 4.5 years. Total number of years in practice and visit volume were the only identified factors associated with being named, suggesting that exposure to higher patient volumes and longer practice experience are the primary contributors to malpractice risk.
We develop and assess variation in an emergency department (ED) admission intensity measure intended for value-based payment models. The measure includes ED diagnoses amenable to evidence-based ...protocols and where admission decisions vary based on physician discretion.
Measure International Classification of Diseases (ICD)-10 codes were selected by face validity by 3 emergency physicians using expertise and administrative data. Feedback was sought from a separate technical panel. Using data from a national group (2018 to 2019), we assessed measure stability at the physician and facility level by quarter using descriptive plots, multilevel linear probability models, and intraclass correlation coefficients (ICC).
A total of 535 ICD-10 measure codes were selected from 23,590 codes. Across 127 EDs, facility-quarter admission rates averaged 26.1% (95% confidence interval CI 24.5 to 27.7). Between- and within-facility standard deviations were 9.2 (95% CI 8.2 to 10.5) and 2.9 (95% CI 2.7 to 3.0), respectively, with an ICC of 0.91. Most ED-quarters (749/961) fell within 2.5% of their facility’s average. Among 2,398 physicians, quarterly rates averaged 29.1% (95% CI 28.6 to 29.6). The between- and within-physician standard deviation was 6.3 (95% CI 6.1 to 6.5) and 5.3 (95% CI 5.3 to 5.4), respectively, with an ICC of 0.58; 220 physicians (9.2%) had an admission rate consistently higher than average and 193 (8.0%) consistently lower.
This set of ICD-10 diagnoses demonstrates face validity and stability for quarterly admission rates at the facility and physician levels. The measure may be useful to monitor facility admission rates in value-based models and reliably identify high and low admitters within facilities to manage admission variation.
It is unknown whether regionalization of postarrest care by interfacility transfer to cardiac arrest receiving centers reduces mortality. We seek to evaluate whether treatment at a cardiac arrest ...receiving center, whether by direct transport or early interfacility transfer, is independently associated with long-term outcome.
We performed a retrospective cohort study including adults resuscitated from out-of-hospital cardiac arrest in southwestern Pennsylvania and neighboring Ohio, West Virginia, and Maryland, which includes approximately 5.7 million residents in urban, suburban, and rural counties. Patients were treated by 1 of 78 ground emergency medical services agencies or 2 air medical transport agencies between January 1, 2010, and November 30, 2014. Our primary exposures of interest were interfacility transfer to a cardiac arrest receiving center within 24 hours of arrest or any treatment at a cardiac arrest receiving center regardless of transfer status. Our primary outcome was vital status, assessed through December 31, 2014, with National Death Index records. We used unadjusted and adjusted survival analyses to test the independent association of cardiac arrest receiving center care, whether through direct or interfacility transport, on mortality.
Overall, 5,217 cases were observed for 3,629 person-years, with 3,865 total deaths. Most patients (82%) were treated at 42 non–cardiac arrest receiving centers with median annual volume of 17 cases (interquartile range 1 to 53 cases per center annually), whereas 18% were cared for at cardiac arrest receiving centers receiving at least 1 interfacility transfer per month. In adjusted models, treatment at a cardiac arrest receiving center was independently associated with reduced hazard of death compared with treatment at a non–cardiac arrest receiving center (adjusted hazard ratio 0.84; 95% confidence interval 0.74 to 0.94). These effects were unchanged when analysis was restricted to patients brought from the scene to the treating hospital. No other hospital characteristic, including total out-of-hospital cardiac arrest patient volume and cardiac catheterization capabilities, independently predicted outcome.
Both early interfacility transfer to a cardiac arrest receiving center and direct transport to a cardiac arrest receiving center from the scene are independently associated with reduced mortality.
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