Association of Clinical Characteristics With Variation in Emergency Physician Preferences for Patients
Association of Clinical Characteristics With Variation in Emergency Physician Preferences for Patients
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DOI：
10.1001/jamanetworkopen.2019.19607
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发表时间：
2020-01-22
影响因子：
13.8
通讯作者：
Obermeyer, Ziad
中科院分区：
文献类型：
--
作者：
Chang, Cindy Y.;Obermeyer, Ziad
重要性医疗保健的广泛差异在很大程度上与医生之间的实践差异有关。医生选择看有更多(或更少)护理需求的患者也可能产生不同医生观察到的护理差异。目的通过测量他们选择看的患者的非随机变化来量化急诊医生的偏好。设计、设置和参与者这项横断面研究使用了来自单个学术医院的电子健康记录系统的大型、详细的临床数据集。数据集包括2010年1月1日至2015年5月31日期间所有成人患者的急诊科(ED)就诊情况，以及急诊科就诊信息。分析了从2018年9月1日到2019年3月31日的数据。将患者分配给特定的急诊医生。急诊医生在选择患者之前看到的患者特征(年龄、性别、敏锐度[紧急严重性指数评分]和合并症)的主要结果和衡量标准，并对时间因素(患者组合中的季节性、每周和每小时的变化)进行了调整。结果本研究分析了62名主治医生的294 915次急诊就诊。在294915例患者中，平均年龄(SD)为48.6岁(19.8岁)，女性为176 690例(59.9%)。许多患者的特征，如年龄(F=2.2；P<；.001)、合并症(F=1.7；P<；.001)和视力(F=4.7；P<；.001)，在统计学上差异显著。与每个特征的最低五分之一的医生相比，最高的五分之一的医生的患者年龄较大(平均年龄分别为47.9[95%CI，47.8-48.1]岁比49.7[95%CI，49.5-49.9]岁；差异，+1.8岁；95%CI，1.5-2.0岁)和病情较重(平均共病分数：0.4[95%CI，0.3-0.5]比1.8[95%CI，1.7-1.8]；差异，+1.3；95%可信区间，1.2-1.4)。这些差异在夜间轮班时不存在或高度减弱，当时只有一名医生值班，患者选择的空间有限。与较早轮班的医生相比，同一位医生轮班较晚的患者较年轻(平均年龄分别为49.7[95%CI，49.4-49.7]岁和44.6[95%CI，44.3-44.9]岁；差异分别为-5.1岁；95%CI，4.8-5.5)和较少的疾病(平均共病分数：0.7[95%CI，0.7-0.8]vs 1.1[95%CI，1.1-1.1]；差异，-0.4；95%可信区间，0.4-0.4)。考虑到偏好的差异，按照ED收费衡量，按护理强度计算的医生排名大幅重新排序，62名医生中有48名(77%)被重新归类到不同的五分之一，12名医生中有9名(75%)被重新归类到较低的五分之一。回归模型显示，22%的ED费用与医生的偏好有关。结论和相关性本研究发现，在换班过程中，医生之间和医生内部的偏好存在差异。这些发现表明，目前减少实践差异的努力可能不会影响与医生偏好相关的差异，这反映了患者需求的潜在差异，而不是医生实践的差异。
IMPORTANCE Much of the wide variation in health care has been associated with practice variation among physicians. Physicians choosing to see patients with more (or fewer) care needs could also produce variations in care observed across physicians.OBJECTIVE To quantify emergency physician preferences by measuring nonrandom variations in patients they choose to see.DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study used a large, detailed clinical data set from an electronic health record system of a single academic hospital. The data set included all emergency department (ED) encounters of adult patients from January 1, 2010, to May 31, 2015, as well as ED visits information. Data were analyzed from September 1, 2018, to March 31, 2019.EXPOSURE Patient assignment to a particular emergency physician.MAIN OUTCOMES AND MEASURES Variation in patient characteristics (age, sex, acuity [Emergency Severity Index score], and comorbidities) seen by emergency physicians before patient selection, adjusted for temporal factors (seasonal, weekly, and hourly variation in patient mix).RESULTS This study analyzed 294 915 visits to the ED seen by 62 attending physicians. Of the 294 915 patients seen, the mean (SD) age was 48.6 (19.8) years and 176 690 patients (59.9%) were women. Many patient characteristics, such as age (F = 2.2; P < .001), comorbidities (F = 1.7; P < .001), and acuity (F = 4.7; P < .001), varied statistically significantly. Compared with the lowest-quintile physicians for each respective characteristic, the highest-quintile physicians saw patients who were older (mean age, 47.9 [95% CI, 47.8-48.1] vs 49.7 [95% CI, 49.5-49.9] years, respectively; difference, +1.8 years; 95% CI, 1.5-2.0 years) and sicker (mean comorbidity score: 0.4 [95% CI, 0.3-0.5] vs 1.8 [95% CI, 1.7-1.8], respectively; difference, +1.3; 95% CI, 1.2-1.4). These differences were absent or highly attenuated during overnight shifts, when only 1 physician was on duty and there was limited room for patient selection. Compared with earlier in the shift, the same physician later in the shift saw patients who were younger (mean age, 49.7 [95% CI, 49.4-49.7] vs 44.6 [95% CI, 44.3-44.9] years, respectively; difference, -5.1 years; 95% CI, 4.8-5.5) and less sick (mean comorbidity score: 0.7 [95% CI, 0.7-0.8] vs 1.1 [95% CI, 1.1-1.1], respectively; difference, -0.4; 95% CI, 0.4-0.4). Accounting for preference variation resulted in substantial reordering of physician ranking by care intensity, as measured by ED charges, with 48 of 62 physicians (77%) being reclassified into a different quintile and 9 of 12 physicians (75%) in the highest care intensity quintile moving into a lower quintile. A regression model demonstrated that 22% of reported ED charges were associated with physician preference.CONCLUSIONS AND RELEVANCE This study found preference variation across physicians and within physicians during the course of a shift. These findings suggest that current efforts to reduce practice variation may not affect the variation associated with physician preferences, which reflect underlying differences in patient needs and not physician practice.