Physician Variability in Management of Emergency Department Patients with Chest Pain
Physician Variability in Management of Emergency Department Patients with Chest Pain
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DOI：
10.5811/westjem.2017.2.32747
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发表时间：
2017-06-01
影响因子：
3.1
通讯作者：
Novack, Victor
中科院分区：
文献类型：
--
作者：
Smulowitz, Peter B.;Barrett, Orit;Novack, Victor
引言：胸痛是一种常见的急诊科（艾德）表现，在美国每年有800 - 1000万人次就诊。医生层面的因素，如风险承受能力是预测入院率。最近出现的加速诊断途径和艾德观察单位可能会对减少个别医生水平入院率的变化产生影响。方法：我们对诊断为胸痛的艾德患者进行了一项单机构回顾性观察研究，由我们医院管理数据库中的诊断代码确定。我们纳入了2012年和2013年的艾德访视。排除了肌钙蛋白升高或心电图（ECG）显示ST段抬高型心肌梗死的患者。患者被分为两组：“入院”（包括观察和住院患者）和“出院”。“我们根据年龄、性别、居住地点和医学院毕业年限对医生进行了分层。我们控制了患者和医院相关因素，包括年龄，性别，种族，保险状况，每日艾德量，和实验室values.Results：4,577例记录的处置，3,252（70.9%）要么入院或观察（在艾德观察单位或在医院），而1,333（29.1%）出院。每名医生的患者中位数为132例（四分位数范围89-172）。平均入院率为73.7 +/- 9.5%，从54%到96%不等。在3，252例住院患者中，2，638例（81.1%）接受观察。有显着的差异，在个别医生水平的入院率与调整后的比值比范围从0.42至5.8相比，平均入院。在医生的特点，年过去了，因为完成医学院表现出一种趋势，与更高的入院probability.Conclusion：有很大的变化，在医生的管理病人出现胸痛，医生的经验发挥了作用。
Introduction: Chest pain is a common emergency department (ED) presentation accounting for 8-10 million visits per year in the United States. Physician-level factors such as risk tolerance are predictive of admission rates. The recent advent of accelerated diagnostic pathways and ED observation units may have an impact in reducing variation in admission rates on the individual physician level.Methods: We conducted a single-institution retrospective observational study of ED patients with a diagnosis 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 two groups: "admission" (this included observation and inpatients) and "discharged." We stratified physicians by age, gender, residency location, and years since medical school. We controlled for patient- and hospital-related factors including age, gender, race, insurance status, daily ED volume, and lab values.Results: Of 4,577 patients with documented dispositions, 3,252 (70.9%) were either admitted to the hospital or into observation (in an ED observation unit or in the hospital), while 1,333 (29.1%) were discharged. Median number of patients per physician was 132 (interquartile range 89-172). Average admission rate was 73.7 +/- 9.5% ranging from 54% to 96%. Of the 3,252 admissions, 2,638 (81.1%) were to observation. There was significant variation in the admission rate at the individual physician level with adjusted 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 association with a higher admission probability.Conclusion: There is substantial variation among physicians in the management of patients presenting with chest pain, with physician experience playing a role.