63 The Impact of a Concierge Medicine Model in the Emergency Department on Diagnostic Test Utilization

Abstract

Study Objectives: The use of a concierge physician model has been employed in the emergency department setting to decrease the door-to-physician time, but this method has been found to concurrently increase the overall ED dwell time by delaying the time needed for medical decisionmaking. The purpose of this study was to identify methodology that could measure the impact of physician testing on patient flow and diagnostic test utilization. We performed a retrospective observational cohort study in an urban academic ED. All available records with adult visits during a 1-month period were reviewed. Patients were analyzed by cohort based on whether or not they were initially seen by a concierge physician prior to formal ED evaluation. The theoretical model identified index tests within categories of physician orders rather than an absolute test count. A complete blood count represented blood work, a chest radiograph represented radiographic imaging, Computed axial tomography (CT) and ultrasound were analyzed independently in the most common body regions. Head and abdomen for CT and abdominal and pelvic for ultrasound. The purpose of this analysis was to give equal weight to testing modalities but not over weight for related tests. The unit cost in our analysis was time and not money, so a complete blood count with a basic metabolic panel and cardiac biomarkers did not significantly add additional time to a patient’s ED stay and were only counted as one test in our index analysis. During the study period, the ED evaluated 9,836 adult patients. Of those, 2,609 (26%) were seen initially by a concierge physician (CP). Patients evaluated by a CP were 1.75 times more likely to have an index test of any sort ordered on them. The probability of at least one order was 0.78 for the CP cohort and .45 for the non-CP cohort. Patients had a mean number of index tests ordered of 1.44 in the CP cohort and 0.78 when not seen initially by a CP physician (95% CI for difference 0.61, 0.70) Using an index test analysis yielded a streamlined evaluation of testing patterns that emerged as a result of a concierge medicine model. This model was more clinically relevant than an absolute test count and easier to implement in ongoing tracking. The index test method would also tend to underestimate the true count of testing (such as extremity radiographs). Placing an administrative emphasis on door-to-physician time had the unintended consequence of nearly doubling the amount of diagnostic testing ordered on patients presenting to an urban ED.