Analysis of Consistency in Emergency Department Physician Variation in Propensity for Admission Across Patient Sociodemographic Groups.
Analysis of Consistency in Emergency Department Physician Variation in Propensity for Admission Across Patient Sociodemographic Groups.
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DOI：
10.1001/jamanetworkopen.2021.25193
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发表时间：
2021-09-01
影响因子：
13.8
通讯作者：
Smulowitz PB
中科院分区：
文献类型：
--
作者：
Khidir H;McWilliams JM;O'Malley AJ;Zaborski L;Landon BE;Smulowitz PB
不同社会人口群体的患者从急诊科收治患者的医生倾向是否一致？在对 2016 年至 2019 年医疗保险索赔数据的横断面分析中，急诊科入院的平均调整率因患者性别、种族和民族以及医疗补助状况而异。医院内各个医生收治的患者比例差异很大，而且这些入院倾向的差异在患者的社会人口统计学群体中是一致的。这项研究的结果表明，从急诊科收治患者的倾向较高或较低的医生在不同患者社会人口群体中表现出一致的相对倾向。医疗保健方面的社会人口差异和医生执业模式的差异已得到充分记录；然而，个体医生护理实践的差异对健康差异的影响很难量化。急诊科 (ED) 医生收治患者的倾向各不相同。这种跨社会人口统计学群体差异的一致性可能有助于确定医生特定因素是否与患者群体之间的护理差异相关。评估不同类别患者性别、种族和民族以及医疗补助登记的急诊医生入院倾向的一致性。这项横断面研究以 10% 的医院随机样本为基础，分析了 2016 年 1 月 1 日至 2019 年 12 月 31 日期间急诊就诊的医疗保险按服务收费索赔情况。在急症护理环境中将患者分配给急诊医生用于隔离入院率的医生级别差异，这反映了医生决策的差异。使用具有医生随机效应和医院固定效应的多水平模型来估计不同患者社会人口亚组的院内医生入院倾向的变异以及亚组之间这些倾向的协变（一致性），并调整主要诊断和合并症。 ED 录取。该分析包括 4-567-760 次急诊就诊，涉及 396 个急诊室的 2-334-361 名受益人和 15-767 名医生。受益人的平均 (SD) 年龄为 78 (8.2) 岁，2 700 661 次就诊 (59.1%) 为女性，大多数患者 (3 839 055 [84.1%]) 不符合医疗补助资格。在 4 473 978 份入组报告中，103 699 名患者 (2.3%) 为亚裔/太平洋岛民，421 588 名患者 (9.4%) 为黑人，257 422 名患者 (5.8%) 为西班牙裔，3 691 269 名患者 (82.5%) 为非西班牙裔白人。在医院内，男性调整后入院率（36.8%；95% CI，36.8%-36.9%）高于女性（33.7%；95% CI，33.7%-33.8%）；非西班牙裔白人 (36.0%; 95% CI, 35.9%-36.0%) 高于亚裔/太平洋岛民 (33.6%; 95% CI, 33.3%-33.9%)、黑人 (30.2%; 95% CI, 30.0%-30.3%) 或西班牙裔 (31.1%; 95% CI, 30.9%-31.2%）受益人；双重参加医疗补助的受益人 (36.3%; 95% CI, 36.2%-36.5%) 高于未参加医疗补助的受益人 (34.7%; 95% CI, 34.7%-34.8%)。在医院内，医生收治的患者比例各不相同，从估计分布的第 10 个百分位的医生的 22.4% 到第 90 个百分位的医生的 47.6%。男性和女性（r = 0.99）、黑人和非西班牙裔白人患者（r = 0.98）以及双重加入和未双重加入医疗补助的患者（r = 0.98）之间的医生入院倾向相关。这项横断面研究表明，尽管总体入院率因患者社会人口因素而存在系统性差异，但个别医生相对于其他医生的入院倾向似乎在患者的社会人口群体中一致适用。这项横断面研究通过社会人口学因素考察了急诊科就诊患者入院率变异性的一致性。
Are physician propensities to admit patients from the emergency department consistent across patient sociodemographic groups? In this cross-sectional analysis of Medicare claims data from 2016 to 2019, the mean adjusted rates of hospital admission from the emergency department differed by patient sex, race and ethnicity, and Medicaid status. Individual physicians varied substantially within hospitals in the percentage of patients they admitted, and these differences in admission propensity were consistent across patient sociodemographic groups. The findings of this study suggest that physicians with higher or lower propensities to admit patients from the emergency department exhibit their relative propensity consistently across patient sociodemographic groups. Sociodemographic disparities in health care and variation in physician practice patterns have been well documented; however, the contribution of variation in individual physician care practices to health disparities is challenging to quantify. Emergency department (ED) physicians vary in their propensity to admit patients. The consistency of this variation across sociodemographic groups may help determine whether physician-specific factors are associated with care differences between patient groups. To estimate the consistency of ED physician admission propensities across categories of patient sex, race and ethnicity, and Medicaid enrollment. This cross-sectional study analyzed Medicare fee-for-service claims for ED visits from January 1, 2016, to December 31, 2019, in a 10% random sample of hospitals. The allocation of patients to ED physicians in the acute care setting was used to isolate physician-level variation in admission rates that reflects variation in physician decision-making. Multi-level models with physician random effects and hospital fixed effects were used to estimate the within-hospital physician variation in admission propensity for different patient sociodemographic subgroups and the covariation in these propensities between subgroups (consistency), adjusting for primary diagnosis and comorbidities. Admission from the ED. The analysis included 4 567 760 ED visits involving 2 334 361 beneficiaries and 15 767 physicians in 396 EDs. The mean (SD) age of the beneficiaries was 78 (8.2) years, 2 700 661 visits (59.1%) were by women, and most patients (3 839 055 [84.1%]) were not eligible for Medicaid. Of 4 473 978 race and ethnicity reports on enrollment, 103 699 patients (2.3%) were Asian/Pacific Islander, 421 588 (9.4%) were Black, 257 422 (5.8%) were Hispanic, and 3 691 269 (82.5%) were non-Hispanic White. Within hospitals, adjusted rates of admission were higher for men (36.8%; 95% CI, 36.8%-36.9%) than for women (33.7%; 95% CI, 33.7%-33.8%); higher for non-Hispanic White (36.0%; 95% CI, 35.9%-36.0%) than for Asian/Pacific Islander (33.6%; 95% CI, 33.3%-33.9%), Black (30.2%; 95% CI, 30.0%-30.3%), or Hispanic (31.1%; 95% CI, 30.9%-31.2%) beneficiaries; and higher for beneficiaries dually enrolled in Medicaid (36.3%; 95% CI, 36.2%-36.5%) than for those who were not (34.7%; 95% CI, 34.7%-34.8%). Within hospitals, physicians varied in the percentage of patients admitted, ranging from 22.4% for physicians at the 10th percentile to 47.6% for physicians at the 90th percentile of the estimated distribution. Physician admission propensities were correlated between men and women (r = 0.99), Black and non-Hispanic White patients (r = 0.98), and patients who were dually enrolled and not dually enrolled in Medicaid (r = 0.98). This cross-sectional study indicated that, although overall rates of admission differ systematically by patient sociodemographic factors, an individual physician’s propensity to admit relative to other physicians appears to be applied consistently across sociodemographic groups of patients. This cross-sectional study examines the consistency of variability in admission rates of patients presenting to the emergency department by sociodemographic factors.
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