{"pk":10366,"title":"Physician Variability in Management of Emergency Department Patients with Chest Pain","subtitle":null,"abstract":"Introduction:\n Chest pain is a common emergency department (ED) presentation accounting for 8-10million visits per year in the United States. Physician-level factors such as risk tolerance are predictive ofadmission rates. The recent advent of accelerated diagnostic pathways and ED observation units mayhave an impact in reducing variation in admission rates on the individual physician level.\nMethods:\n We conducted a single-institution retrospective observational study of ED patients with adiagnosis of chest pain as determined by diagnostic code from our hospital administrative database.We included ED visits from 2012 and 2013. Patients with an elevated troponin or an electrocardiogram(ECG) demonstrating an ST elevation myocardial infarction were excluded. Patients were divided into twogroups: “admission” (this included observation and inpatients) and “discharged.” We stratified physiciansby age, gender, residency location, and years since medical school. We controlled for patient- andhospital-related factors including age, gender, race, insurance status, daily ED volume, and lab values.\nResults:\n Of 4,577 patients with documented dispositions, 3,252 (70.9%) were either admitted to thehospital or into observation (in an ED observation unit or in the hospital), while 1,333 (29.1%) weredischarged. Median number of patients per physician was 132 (interquartile range 89-172). Averageadmission rate was 73.7±9.5% ranging from 54% to 96%. Of the 3,252 admissions, 2,638 (81.1%) wereto observation. There was significant variation in the admission rate at the individual physician level withadjusted odds ratio ranging from 0.42 to 5.8 as compared to the average admission. Among physicians’characteristics, years elapsed since finishing medical school demonstrated a trend towards associationwith a higher admission probability.\nConclusion:\n There is substantial variation among physicians in the management of patients presentingwith chest pain, with physician experience playing a role.","language":"en","license":{"name":"Creative Commons Attribution 4.0","short_name":"CC BY 4.0","text":"Attribution — You must give appropriate credit, provide a link to the license, and indicate if changes were made. You may do so in any reasonable manner, but not in any way that suggests the licensor endorses you or your use.\r\n\r\nNo additional restrictions — You may not apply legal terms or technological measures that legally restrict others from doing anything the license permits.","url":"https://creativecommons.org/licenses/by/4.0"},"keywords":[{"word":"chest pain, emergency department, small area variation"}],"section":"Practice Variability","is_remote":true,"remote_url":"https://escholarship.org/uc/item/7n63q0xv","frozenauthors":[{"first_name":"Peter","middle_name":"B.","last_name":"Smulowitz","name_suffix":"","institution":"Beth Israel Deaconess Medical Center, Harvard Medical School, Department of Emergency Medicine, Boston, Massachusetts","department":"None"},{"first_name":"Orit","middle_name":"","last_name":"Barrett","name_suffix":"","institution":"Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Department of Medicine and Clinical Research Center, Be’er Sheva, Israel","department":"None"},{"first_name":"Matthew","middle_name":"M.","last_name":"Hall","name_suffix":"","institution":"Beth Israel Deaconess Medical Center, Harvard Medical School, Department of\nEmergency Medicine, Boston, Massachusetts","department":"None"},{"first_name":"Shamai","middle_name":"A.","last_name":"Grossman","name_suffix":"","institution":"Beth Israel Deaconess Medical Center, Harvard Medical School, Department of Emergency Medicine, Boston, Massachusetts","department":"None"},{"first_name":"Edward","middle_name":"A.","last_name":"Ullman","name_suffix":"","institution":"Beth Israel Deaconess Medical Center, Harvard Medical School, Department of Emergency Medicine, Boston, Massachusetts","department":"None"},{"first_name":"Victor","middle_name":"","last_name":"Novak","name_suffix":"","institution":"Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Department of Internal Medicine, Be’er Sheva, Israel","department":"None"}],"date_submitted":"2016-10-03T23:20:51-07:00","date_accepted":"2016-10-03T23:20:51-07:00","date_published":"2017-04-17T12:24:20-07:00","render_galley":null,"galleys":[{"label":"","type":"pdf","path":"https://journalpub.escholarship.org/westjem/article/10366/galley/5700/download/"}]}