Emergency Department Physician Computed Tomography Utilization and Admission Rates

Abstract

Study ObjectivesThe wide variation in computed tomography (CT) use and admission rates between emergency physicians may indicate excessive use of these resources by some. CT use has been shown to reduce admissions for abdominal pain and potential acute coronary syndrome, suggesting that use of CT by emergency physicians may decrease admission rates. We examine the association between CT use and admission and hypothesize that the same physicians consistently use these resources at higher rates than their peers.MethodsThis was a retrospective study of board certified/eligible emergency physicians practicing at an 850 bed tertiary level 1 trauma center and children's hospital with 85,000 care visits annually. Emergency physicians are assigned to all areas of the emergency department (ED) on an equal basis. Physicians were excluded if they worked primarily in the pediatric ED. Data was obtained from an electronic medical record with physician order entry over a 3.5-year period (Aug 2008 to Jan 2012). CT scans and admissions were attributed to a provider if they were the ordering provider and the physician of record. We excluded urgent care patients, patients under age 8, and trauma activations. CT rates were modeled for providers as a function of Emergency Severity Index (ESI), patient age, time of presentation, and ED disposition. Logistic regression was used to provide a measure of CT ordering that is comparable between providers. Admission rates were modeled using logistic regression as a function of ESI, patient age, and time of presentation. Admission rates were calculated for overall admissions and common chief complaints. Pearson's r and odds ratios were calculated to determine correlation of use of multiple resources.ResultsThere were 48 eligible emergency physicians with a mean of 2,494 clinical hours worked and 3,949 patients seen. There were 193,532 eligible visits and 44,724 visits where a patient received a CT scan. The rate of CT ordering by providers was 23.8% (95%CI 23.4-24.2%) of patient visits, ranging from 11.5% (95%CI 9.2-14.4%) to 32.7% (95%CI 31.0-34.5%). There were 57,213 admissions to the hospital. The mean number of admissions was 1168 patients. The admission rate was 23.6% (95%CI 22.9-24.3%) of visits ranging from 17.4% (95% CI 16.2-18.6%) to 33.6% (95%CI 32.3-34.8%). Odds ratio of a physician with high CT use and a high admission rate was 4.29 (95%CI 1.06-17.4). Pearson's r for CT use and admissions was 0.56 (p<0.0001). There was a strong to medium correlation between CT use and admission rates for chest pain 0.52 (p=0.0001), shortness of breath 0.38 (p=0.006), and abdominal pain 0.31 (p=0.03). Odds ratio of high CT use and high admission for chest pain was 4.29 (95%CI 1.06-17.4).ConclusionsWe demonstrate a strong correlation between provider admission rates and CT use. The correlation between CT use and admissions for chest pain and abdominal pain may contradict previous findings that CT use always decreases admissions for specific conditions. Physicians with high admission rates and high CT use suggest that a small cohort will consistently over utilize resources. A factor common to this group of providers, such as risk aversion, likely accounts for increased use of these resources and outweighs the current evidence of CT's role in safe discharges. Future attempts to lower resource utilization need to focus on the factors influencing these physicians rather than targeting the resource itself. Study ObjectivesThe wide variation in computed tomography (CT) use and admission rates between emergency physicians may indicate excessive use of these resources by some. CT use has been shown to reduce admissions for abdominal pain and potential acute coronary syndrome, suggesting that use of CT by emergency physicians may decrease admission rates. We examine the association between CT use and admission and hypothesize that the same physicians consistently use these resources at higher rates than their peers. The wide variation in computed tomography (CT) use and admission rates between emergency physicians may indicate excessive use of these resources by some. CT use has been shown to reduce admissions for abdominal pain and potential acute coronary syndrome, suggesting that use of CT by emergency physicians may decrease admission rates. We examine the association between CT use and admission and hypothesize that the same physicians consistently use these resources at higher rates than their peers. MethodsThis was a retrospective study of board certified/eligible emergency physicians practicing at an 850 bed tertiary level 1 trauma center and children's hospital with 85,000 care visits annually. Emergency physicians are assigned to all areas of the emergency department (ED) on an equal basis. Physicians were excluded if they worked primarily in the pediatric ED. Data was obtained from an electronic medical record with physician order entry over a 3.5-year period (Aug 2008 to Jan 2012). CT scans and admissions were attributed to a provider if they were the ordering provider and the physician of record. We excluded urgent care patients, patients under age 8, and trauma activations. CT rates were modeled for providers as a function of Emergency Severity Index (ESI), patient age, time of presentation, and ED disposition. Logistic regression was used to provide a measure of CT ordering that is comparable between providers. Admission rates were modeled using logistic regression as a function of ESI, patient age, and time of presentation. Admission rates were calculated for overall admissions and common chief complaints. Pearson's r and odds ratios were calculated to determine correlation of use of multiple resources. This was a retrospective study of board certified/eligible emergency physicians practicing at an 850 bed tertiary level 1 trauma center and children's hospital with 85,000 care visits annually. Emergency physicians are assigned to all areas of the emergency department (ED) on an equal basis. Physicians were excluded if they worked primarily in the pediatric ED. Data was obtained from an electronic medical record with physician order entry over a 3.5-year period (Aug 2008 to Jan 2012). CT scans and admissions were attributed to a provider if they were the ordering provider and the physician of record. We excluded urgent care patients, patients under age 8, and trauma activations. CT rates were modeled for providers as a function of Emergency Severity Index (ESI), patient age, time of presentation, and ED disposition. Logistic regression was used to provide a measure of CT ordering that is comparable between providers. Admission rates were modeled using logistic regression as a function of ESI, patient age, and time of presentation. Admission rates were calculated for overall admissions and common chief complaints. Pearson's r and odds ratios were calculated to determine correlation of use of multiple resources. ResultsThere were 48 eligible emergency physicians with a mean of 2,494 clinical hours worked and 3,949 patients seen. There were 193,532 eligible visits and 44,724 visits where a patient received a CT scan. The rate of CT ordering by providers was 23.8% (95%CI 23.4-24.2%) of patient visits, ranging from 11.5% (95%CI 9.2-14.4%) to 32.7% (95%CI 31.0-34.5%). There were 57,213 admissions to the hospital. The mean number of admissions was 1168 patients. The admission rate was 23.6% (95%CI 22.9-24.3%) of visits ranging from 17.4% (95% CI 16.2-18.6%) to 33.6% (95%CI 32.3-34.8%). Odds ratio of a physician with high CT use and a high admission rate was 4.29 (95%CI 1.06-17.4). Pearson's r for CT use and admissions was 0.56 (p<0.0001). There was a strong to medium correlation between CT use and admission rates for chest pain 0.52 (p=0.0001), shortness of breath 0.38 (p=0.006), and abdominal pain 0.31 (p=0.03). Odds ratio of high CT use and high admission for chest pain was 4.29 (95%CI 1.06-17.4). There were 48 eligible emergency physicians with a mean of 2,494 clinical hours worked and 3,949 patients seen. There were 193,532 eligible visits and 44,724 visits where a patient received a CT scan. The rate of CT ordering by providers was 23.8% (95%CI 23.4-24.2%) of patient visits, ranging from 11.5% (95%CI 9.2-14.4%) to 32.7% (95%CI 31.0-34.5%). There were 57,213 admissions to the hospital. The mean number of admissions was 1168 patients. The admission rate was 23.6% (95%CI 22.9-24.3%) of visits ranging from 17.4% (95% CI 16.2-18.6%) to 33.6% (95%CI 32.3-34.8%). Odds ratio of a physician with high CT use and a high admission rate was 4.29 (95%CI 1.06-17.4). Pearson's r for CT use and admissions was 0.56 (p<0.0001). There was a strong to medium correlation between CT use and admission rates for chest pain 0.52 (p=0.0001), shortness of breath 0.38 (p=0.006), and abdominal pain 0.31 (p=0.03). Odds ratio of high CT use and high admission for chest pain was 4.29 (95%CI 1.06-17.4). ConclusionsWe demonstrate a strong correlation between provider admission rates and CT use. The correlation between CT use and admissions for chest pain and abdominal pain may contradict previous findings that CT use always decreases admissions for specific conditions. Physicians with high admission rates and high CT use suggest that a small cohort will consistently over utilize resources. A factor common to this group of providers, such as risk aversion, likely accounts for increased use of these resources and outweighs the current evidence of CT's role in safe discharges. Future attempts to lower resource utilization need to focus on the factors influencing these physicians rather than targeting the resource itself. We demonstrate a strong correlation between provider admission rates and CT use. The correlation between CT use and admissions for chest pain and abdominal pain may contradict previous findings that CT use always decreases admissions for specific conditions. Physicians with high admission rates and high CT use suggest that a small cohort will consistently over utilize resources. A factor common to this group of providers, such as risk aversion, likely accounts for increased use of these resources and outweighs the current evidence of CT's role in safe discharges. Future attempts to lower resource utilization need to focus on the factors influencing these physicians rather than targeting the resource itself.