Physician Resource Utilization Research Articles

Emergency physician resource utilization varies by years of experience.

One of the most pivotal decisions an emergency physician (EP) makes is whether to admit or discharge a patient. The emergency department (ED) work-up leading to this decision involves several resource-intensive tests. Previous studies have demonstrated significant differences in EP resource utilization, measured by lab tests, advanced imaging (magnetic resonance imaging [MRI], computed tomography [CT], ultrasound), consultations, and propensity to admit a patient. However, how an EP's years of experience may impact their resource utilization and propensity to admit patients has not been well characterized. This study seeks to better understand how EPs' years of experience, post-residency, relates to their use of advanced imaging and patient disposition. Ten years of ED visits were analyzed for this study from a single, academic tertiary care center in the urban Northeast United States. The primary outcomes were utilization of advanced imaging during the visit (CT, MRI, or formal ultrasound) and whether the patient was admitted. EP years of experience was categorized into 0-2years, 3-5years, 6-8years, 9-11years, and 12 or more years. Patient age, sex, Emergency Severity Index (ESI), and the attending EP's years of experience were collected. The relationship between EP years of experience and each outcome was assessed with a linear mixed model with a random effect for provider and patient age, sex, and ESI as covariates. A total of 460,937 visits seen by 65 EPs were included in the study. Over one-third (37.6%) of visits had an advanced imaging study ordered and nearly half (49.5%) resulted in admission. Compared to visits with EPs with 0-2years of experience, visits with EPs with 3-5 or 6-8years of experience had significantly lower odds of advanced imaging occurring. Visits seen by EPs with more than 2 years of experience had lower odds of admission than visits by EPs with 0-2years of experience. More junior EPs tend to order more advanced imaging studies and have a higher propensity to admit patients. This may be due to less comfort in decision-making without advanced imaging or a lower risk tolerance. Conversely, the additional clinical experience of the most senior EPs, with greater than 9years of experience,likely impacts their resource utilization patterns such that their use of advanced imaging does not significantly differ from the most junior EPs.

Association between physician resource utilization, throughput, and patient experience in the emergency department

Background and Importance: Emergency department (ED) care is complex, involving multifaceted factors such as patient volume, provider experience, throughput metrics, and patient-provider interactions. While some studies have explored relationships between these parameters, there is still much to understand about the nuances in ED care. Objective: Our study aimed to analyze the statistical relationships between admission rates, Press Ganey (PG) scores, and various throughput/resource utilization variables in the ED. These variables include imaging and lab ordering rates, door-to-doctor (D2D) success rate, disposition times for specific patient acuities, and elopement or discharge against medical advice (AMA) rates. Design: A retrospective cohort study was conducted using data from eight emergency facilities within the Valley Health System. Settings and Participants: Data from six community hospital EDs and two freestanding emergency departments (FEDs) in the Valley Health System, spanning August 1, 2020, to July 31, 2021, were examined. The analysis involved 99 physicians and approximately 200,000 adult patients. Outcome Measures and Analysis: Correlations between admission rates, PG scores, and various ED metrics were examined using the Jamovi software. Separate analyses were conducted based on facility type using ANOVAs. Main Results: Our findings revealed several significant correlations. There was a positive correlation between lab ordering and admission rates, while D2D success rates showed a negative correlation with admission rates. Additionally, there was a positive association between D2D success rates and quick dispositioning of lower acuity patients. Patient satisfaction (PG score) was negatively correlated with admission, AMA, and D2D success rates, whereas it positively correlated with lab ordering rates. Conclusion: This study identifies significant relationships among ED throughput, resource utilization, and patient satisfaction metrics. These findings can guide further research to understand the patient experience better, optimize resource utilization, and improve overall ED efficiency.

Association between physician resource utilization, throughput, and patient experience in the emergency department

Association between physician resource utilization, throughput, and patient experience in the emergency department

AP-453071-5 SHOCKED BY EFFICIENCY: PATIENTS RECEIVE QUALITY CARE IN AN ALLIED PROFESSIONAL CARDIOVERSION PROGRAM THAT ALLEVIATES LAYERS OF SYSTEMIC STRAIN

Performance of electrical cardioversion (CV) for atrial fibrillation (AF) by allied professionals (APs) can reduce physician resource utilization and may be associated with greater efficiency without compromising patient safety. To demonstrate that a cardioversion service overseen and performed by APs is associated with improved efficiency and reduced physician utilization while maintaining patient safety. In July 2020, we initiated a protocol whereby electrophysiology APs were trained, privileged, and credentialed to independently perform CVs at our institution. Each AP performed ten supervised CVs and subsequently proceeded independently with periprocedural documentation, CV performance, coordination of care, and patient education for those referred to the program. An analysis was performed assessing a cohort of patients (randomly selected from 2018-2022) to compare the average patient length of stay and adverse events under the EP AP service vs the EP/Cardiologist service. Since the initiation of the AP CV protocol (from July 2020 to November 2022), there were 422 CVs performed by an AP out of 1,048 total CVs. A chart review was performed assessing a random cohort of 104 CVs from 2018-2022: 52 (50%) by APs and 52 (50%) by MDs. The average length of stay in the procedure suite for AP CV was 90.8±26.3min vs 114.1±33.5min when performed by a physician, representing a time savings of 23.3min per patient (p <0.01). In addition, the time from outpatient elective CV order to time of CV was 18.4±11.8 days for APs vs 19.4±12.5 days for physicians. There were no adverse events in any of the AP CVs. The APs involved in the CV service universally felt that this independent activity improved job satisfaction. Independent performance of CVs by APs is significantly more time efficient without compromise in patient safety. Additional benefits to the EP AP CV service include improved scheduling availability, easier coordination with anesthesia services, offloading of physician workload, and increased AP job satisfaction.

Not All Testers are Admitters: An Analysis of Emergency Physician Resource Utilization and Consultation Rates

Variability exists in emergency physician (EP) resource utilization as measured by ordering practices, rate of consultation, and propensity to admit patients. To validate and expand upon previous data showing that resource utilization as measured by EP ordering patterns is positively correlated with admission rates. This is a retrospective study of routinely gathered operational data from the ED of an urban academic tertiary care hospital. We collected individual EP data on advanced imaging, consultation, and admission rates per patient encounter. To investigate whether there might be distinct groups of practice patterns relating these 3 resources, we used a Gaussian mixture model, a classification method used to determine the likelihood of distinct subgroups within a larger population. Our Gaussian mixture model revealed 3 distinct groups of EPs based on their ordering practices. The largest group is characterized by a homogenous pattern of neither high or low resource utilization (n=37, 27% female, median years' experience: 6 [interquartile ratio {IQR} 3-18]; rates of advanced imaging, 38.9%; consultation, 45.1%; and admission 39.3%), with a modest group of low-resource users (n=15, 60% female, median years' experience: 6 [IQR 5-14]; rates of advanced imaging, 37%; consultation, 42.6%; and admission 37.3%), and far fewer members of a high-resource use group (n=6, 0% female, median years' experience: 6 [IQR 4-16]; rates of advanced imaging, 42.2%; consultation, 45.8%; and admission 40.6%). This variation suggests that not "all testers are admitters," but that there exist wider practice variations among EPs. At our academic tertiary center, 3 distinct subgroups of EP ordering practices exist based on consultation rates, advanced imaging use, and propensity to admit a patient. These data validate previous work showing that resource utilization and admission rates are related, while demonstrating that more nuanced patterns of EP ordering practices exist. Further investigation is needed to understand the impact of EP characteristics and behavior on throughput and quality of care. © 2022 Elsevier Inc.

Are testers also admitters? Comparing emergency physician resource utilization and admitting practices

ObjectiveTo describe the relationship between emergency department resource utilization and admission rate at the level of the individual physician. MethodsRetrospective observational study of physician resource utilization and admitting data at two emergency departments. We calculated observed to expected (O/E) ratios for four measures of resource utilization (intravenous medications and fluids, laboratory testing, plain radiographs, and advanced imaging studies) as well as for admission rate. Expected values reflect adjustment for patient- and time-based variables. We compared O/E ratios for each type of resource utilization to the O/E ratio for admission for each provider. We report degree of correlation (slope of the trendline) and strength of correlation (adjusted R2 value) for each association, as well as categorical results after clustering physicians based on the relationship of resource utilization to admission rate. ResultsThere were statistically significant positive correlations between resource utilization and physician admission rate. Physicians with lower resource utilization rates were more likely to have lower admission rates, and those with higher resource utilization rates were more likely to have higher admission rates. ConclusionsIn a two-facility study, emergency physician resource utilization and admission rate were positively correlated: those who used more ED resources also tended to admit more patients. These results add to a growing understanding of emergency physician variability.

Physician Specialty and Radiologist Characteristics Associated with Higher Medicare Patient Complexity

Meaningfully measuring physician outcomes and resource utilization requires appropriate patient risk adjustment. We aimed to assess Medicare patient complexity by physician specialty and to further identify radiologist characteristics associated with higher patient complexity. The average beneficiary Hierarchical Condition Category (HCC) risk scores (Medicare's preferred measure of clinical complexity) were identified for all physicians using 2014 Medicare claims data. HCC scores were compared among physician specialties and further stratified for radiologists based on a range of characteristics. Univariable and multivariable analyses were performed. Of 549,194 physicians across 54 specialties, the mean HCC risk score was 1.62 ± 0.75. Of the 54 specialties, interventional radiology ranked 4th (2.60 ± 1.29), nuclear medicine ranked 16th (1.87 ± 0.45), and diagnostic radiology ranked 21st (1.75 ± 0.61). Among 31,175 radiologists, risk scores were higher (P < 0.001) for those with teaching (2.03 ± 0.74) vs nonteaching affiliations (1.72 ± 0.61), practice size ≥100 (1.94 ± 0.70) vs ≤9 (1.59 ± 0.79) members, urban (1.79 ± 0.69) vs rural (1.67 ± 0.59) practices, and subspecialized (1.85 ± 0.81) vs generalized (1.68 ± 0.42) practice patterns. Among noninterventional radiology subspecialties, patient complexity was highest for cardiothoracic (2.09 ± 0.57) and lowest for breast (1.08 ± 0.32) imagers. At multivariable analysis, a teaching affiliation was the strongest independent predictor of patient complexity for both interventional (β = +0.23, P = 0.005) and noninterventional radiologists (β = +0.21, P < 0.001). Radiologists on average serve more clinically complex Medicare patients than most physicians nationally. However, patient complexity varies considerably among radiologists and is particularly high for those with teaching affiliations and interventional radiologists. With patient complexity increasingly recognized as a central predictor of clinical outcomes and resource utilization, ongoing insights into complexity measures may assist radiologists navigating emerging risk-based payment models.

Impact of income-based deductibles on drug use and health care utilization among older adults.

Income-based deductibles are present in several provincial public drug plans in Canada and have been the subject of extensive debate. We studied the impact of such deductibles in British Columbia's Fair PharmaCare plan on drug and health care utilization among older adults. We used a quasi-experimental regression discontinuity design to compare the impact of deductibles in BC's PharmaCare plan between older community-dwelling adults registered for the plan who were born in 1928 through 1939 (no deductible) and those born in 1940 through 1951 (deductible equivalent to 2% of household income). We used 1.2 million person-years of data between 2003 and 2015 to study public drug plan expenditures, overall drug use, and physician and hospital resource utilization in these 2 groups. The income-based deductible led to a 28.6% decrease in person-years in which public drug plan benefits were received (95% confidence interval [CI] -29.7% to -27.5%) and to a reduction in the per capita extent of annual benefits by $205.59 (95% CI -$247.81 to -$163.37). Despite this difference in public subsidy, we found no difference in the number of drugs received or in total drug spending once privately paid amounts were accounted for (p = 0.4 and 0.8, respectively). Further, we found only small or nonexistent changes in health care resource utilization at the 1939 threshold. A modest income-based deductible had a considerable impact on the extent of public subsidy for prescription drugs. However, it had only a trivial impact on overall access to medicines and use of other health services. Unlike copayments, modest income-based deductibles may safely reduce public spending on drugs for some population groups.

Operant Conditioning and the Practice of Defensive Medicine

n the United States, the enormous burden of health care expenditure on the national budget and the role of physiI cians in controlling these costs are under scrutiny. The Centers for Medicare and Medicaid Services estimates that national health care expenditure in 2014 accounted for 17.5% of the gross domestic product in the United States, reaching almost $3 trillion; although all aspects of medicine saw cost increases, the growth rate increase in expenditure on physician and clinical services nearly doubled. This situation dominates every budgetary discussion at federal, state, and local municipality levels. Cost reductions are a priority, as is a careful analysis of physician practices and resource utilization. Most, but not all, practicing physicians mature through a process of residency training and board certification. In the United States, national boards, such as the American Board of Neurological Surgery, assiduously ensure a high level and uniformity of physician competency. Certification is an arduous process, and it requires demonstration of knowledge, competency, and careful judgment; it provides a measure of physician excellence. However, the American Board of Neurological Surgery and other similar bodies have little control over the utilization of resources by physicians once they enter practice.

Objective and Subjective Assessment of Physician Labor and Resource Utilization in Maintenance Percutaneous Transluminal Angioplasty of Nonthrombosed Hemodialysis Arteriovenous Fistulas versus Arteriovenous Grafts

PurposeTo complement prior studies that have shown that arteriovenous fistula (AVF) thrombectomies require more time and equipment than arteriovenous graft (AVG) thrombectomies by measuring work via established instruments to determine whether there is also a difference in maintenance percutaneous transluminal angioplasty (PTA) of nonthrombosed AVFs versus AVGs. Materials and MethodsPTA procedures performed on a consecutive cohort of 42 patients with AVFs and 27 patients with AVGs were prospectively compared. To quantify resource utilization, procedure time and disposable equipment were measured. Established instruments developed by the American Medical Association for Current Procedural Terminology code valuation were used to measure subjective “physician work,” including mental effort and judgment, technical skill, physical effort, and psychological stress. These items were scored by 1 of 12 attending interventional radiology physicians performing the procedure. ResultsMean PTA procedure time was 74 minutes (range, 18–183 minutes) for AVFs and 71 minutes (range, 28–204 minutes) for AVGs; hemostasis time was 12 minutes for AVFs and 11 minutes for AVGs. There was no significant difference in equipment use between groups. “Physician work” for AVFs scored significantly higher in four categories (P≤ .05). ConclusionsUsing established subjective instruments, maintenance PTA of AVFs was scored as more cognitively, physically, and psychologically demanding than maintenance PTA of AVGs. However, there was no significant difference in resource utilization between maintenance PTA of AVFs versus AVGs, as has been previously shown with thrombectomy of thrombosed AVFs and AVGs.

The Impact of Infection After Total Hip Arthroplasty on Hospital and Surgeon Resource Utilization

Deep infection following total hip arthroplasty is a devastating complication for the patient and a costly one for patients, surgeons, hospitals, and payers. The purpose of this study was to compare revision total hip arthroplasty for infection, revision total hip arthroplasty for aseptic loosening, and primary total hip arthroplasty with respect to their impact on hospital and surgeon resource utilization and referral patterns to a tertiary-care hospital. Clinical, demographic, and economic data were obtained for twenty-five consecutive patients with an infection after a total hip replacement who underwent a two-stage revision arthroplasty (Group 1) performed by one of two surgeons, between March 2001 and December 2002, at a single institution. Similar data were collected during the same time-period for a cohort of twenty-five consecutive patients who underwent revision of both components because of aseptic loosening (Group 2) and twenty-five consecutive patients who underwent a primary hip arthroplasty (Group 3). Quantitative and categorical variables were compared among the groups. Referral patterns were examined by reviewing the primary diagnosis for all patients referred to our institution for a revision total hip arthroplasty during a five-year period. Revision procedures for infection were associated with longer operative time, more blood loss, and a higher number of complications compared with revisions for aseptic loosening or primary total hip arthroplasty (p < 0.02 for all). Revisions for infection were also associated with a higher total number of hospitalizations, total number of days in the hospital, total number of operations, total hospital costs, total outpatient visits, and total outpatient charges during the twelve-month period following the index procedure (p < 0.001 for all). The incidence of referrals to our institution for a diagnosis of infection following total hip arthroplasty increased significantly over a five-year period (Spearman rank correlation, 1.0; p = 0.0083), while referral rates for revision for causes other than infection remained relatively constant (Spearman rank correlation, 0.500; p = 0.3910). The treatment of patients with an infection after a total hip arthroplasty is associated with significantly greater hospital and physician resource utilization compared with the treatment of patients who have a revision because of aseptic loosening or who have a primary total hip arthroplasty. We believe that the lack of incremental reimbursement associated with these procedures results in strong financial disincentives for physicians and hospitals to provide treatment for patients with an infection after a total hip arthroplasty.

Determinants of PHC productivity and resource utilization: a comparison of public and private physicians in Macedonia

The dominant reform paradigm for developing countries introduces market forces into health care provision to improve quality and efficiency. Yet, there is very little empirical evidence as to how individual physicians respond to such incentives. Using a survey of primary health care providers in the Republic of Macedonia, the effect of privatization on physician workload and resource utilization is examined. The survey of physicians in public and private clinics provides extensive data on physician demographics, practice patterns and capital inputs, with an innovation being a measure of physician skill based on responses to several clinical vignettes. Physician production of patient visits is modeled as a jointly determined process of workload and input utilization. Such a formulation acknowledges the endogeneity of input and output and, more importantly, allows the straightforward estimation of the demand equations for labor and capital inputs. Controlling for physician and practice characteristics, private physicians do exhibit higher productivity and greater capital resource use per patient. Major factors influencing workload and resource use are skill and referral rates, both of which have important implications for designing comprehensive and effective physician incentive systems.

Using Clinical Practice Analysis to Improve Care

Improving clinical outcomes requires that physicians examine and change their clinical practice. Sustaining outcome improvements requires a dedicated and dynamic program of analyzing and improving patient care. In 1992 North Mississippi Health Services (NMHS) implemented a program to improve physicians' clinical efficiency. CLINICAL PRACTICE ANALYSIS ( CPA): CPA uses evidenced-based guidelines and examines each physician's resource utilization, processes, and outcomes for a diagnosis or procedure. Clinical practice profiles are developed, and individual performance is compared to local and national benchmarks and presented to physicians. The CPA process is used on its own or as a component of more comprehensive performance improvements projects. Physicians have been engaged in outcome improvement by more than 55 CPA projects. NHMS has progressively reduced its Medicare loss and its length of stay (LOS) to 4.9 days. Mortality and readmission rates have been reduced in specific diagnoses. The community-acquired pneumonia project reduced the LOS from 7.7 to 5.1 days, decreaesed the mortality rate from 8.9% to 5.0%, and decreased the cost of care from $4,269 to $3,834. The ischemic stroke project reduced the aspiration pneumonia rate from 6.4% to 0% and mortality from 11.0% to 4.6%. Patients' average LOS decreased from 10.7 days to 6.5 days, and their cost of care was reduced by $1,100 per patient. Providing individualized data has engaged physicians in improving outcomes. The program has evolved from improving efficiency to managing outcomes and from simple CPA projects to integrated performance improvement projects; however, the CPA process remains the cornerstone of the current process.

4577 Physician resource utilization for endoscopic ultrasound vs. ercp.

INTRODUCTION: EUS and ERCP each represent hybrids of endoscopy and radiology that require special expertise and equipment. Despite these similarities, reimbursement for EUS is less than for ERCP. HYPOTHESIS: Physician resource utilization for EUS and ERCP as determined by procedure length is similar. AIM: Compare EUS and ERCP procedure lengths from a large multicenter database. METHODS: We performed a retrospective review of the CORI (Clinical Outcomes Research Initiative) database of all EUS (recorded 2/4/98 - 6/30/99) and ERCPs (recorded 6/30/97 - 6/30/99). Data were analyzed as to demographics and procedure length (minutes) of upper EUS vs ERCP, with subset analysis of EUS with fine needle aspiration (FNA) vs. therapeutic ERCP (ERCP with at least one therapeutic procedure: sphincterotomy, stent placement/replacement, stone removal, dilation). Statistical analysis was performed using the JMP module of SAS software. P-values were calculated using Student's T-test. RESULTS: 1452 upper EUS exams (65% male & 35% female) and 2110 ERCPs (57% male & 43% female) were recorded during the periods specified. EUS was performed by 42 endoscopists (60% University based, 40% VA based) at 19 sites (50% University, 50% VA). ERCP was performed by 103 endoscopists (60% University based, 28% VA based, 12% private practice) at 28 sites (69% University, 23% VA, 8% private practice). The mean age of patients undergoing upper EUS vs. ERCP was 61.0±13.6 yrs vs. 55.3 ± 17.5 yrs (mean ± SD, p<0.0001). Data on procedure length was available in 1073(74%) of upper EUS cases vs. 1380(65%) of ERCPs. The mean procedure length of upper EUS vs. ERCP was only 2 1/2 minutes different: 39.8 ± 22.7 min vs. 42.3 ± 26.2 min (mean ± SD,p=0.01). When comparing EUS with FNA (n=318) to therapeutic ERCP (n=615), data on procedure length was available in 215(68%) and 379(62%) cases, respectively. The mean procedure length of EUS with FNA vs. therapeutic ERCP was 61.2 ± 23.3 min vs. 47.7 ± 28.2 min (mean ± SD,p<0.0001). CONCLUSIONS:(1) Resource utilization as reflected in the average procedure length is similar for EUS and ERCP. (2)The average procedure length of EUS with FNA is substantially longer than therapeutic ERCP. (3) Given the complexity of both procedures, procedure lengths, need for additional specialized training, and demands on technical/nursing support, these data favor at least equal financial reimbursement for EUS procedures.

Applying the resource-based relative value scale to the emory angioplasty versus surgery trial

The resource-based relative value scale developed for use in the Medicare fee schedule can also be very useful in profiling and comparing physicians’ cardiovascular utilization across different medical activities. This article applies relative value units (RVUs) to data from the Emory Angioplasty versus Surgery Trial. The Emory Angioplasty versus Surgery Trial was a randomized clinical trial to determine the efficacy of percutaneous transluminal coronary angioplasty (PTCA) versus coronary artery bypass surgery (CABG). All physician services in the clinical trial provided to 2 groups of patients—those undergoing CABG and those receiving PTCA—over the course of 4 years were assigned physician work RVUs (representing the intensity of physician work required) and total RVUs (representing both the intensity and practice costs). Physician charges were also compiled. These data were used to profile and compare physician services to the 2 groups of patients by type of service, distribution over time, and clinical department. Comparisons based on RVUs contrast sharply with differences based on charges. Mean physician charges, in 1996 dollars, were $27,158 for CABG patients and $21,491 for PTCA patients, a 26% difference (p <0.001). Physician work RVUs generated an 18.3% difference (p = <0.001). Using total RVUs, the difference between the 2 groups was 3.3% (p = 0.249). Resource-based relative value weights are a valuable tool for analyzing and comparing physicians’ use of cardiovascular resource. The results suggest that conclusions about physician resource utilization based on physician charges should be carefully evaluated. When possible, physician work RVUs should be compiled and evaluated along with physician charges.

Casemix adjustment of managed care claims data using the clinical classification for health policy research method.

The objective of this study was to explore the use of the Clinical Classification for Health Policy Research (CCHPR) as a casemix adjustment method for examining physician practice patterns. The data source was 2 years of administrative claims from an 86,000 member health maintenance organization in southeastern Michigan. The CCHPR version 2 algorithm, which is in the public domain, was used to assign each claim to one of 260 clinical categories. CCHPR and age-sex categories were used as explanatory variables in multiple linear regression models with approved claims payments in dollars as the outcome variable. Regressions were performed retrospectively for 1994 and 1995, and with 1994 claims' history to predict 1995 utilization. Similar regressions were performed with age-sex categories alone, and also with the ambulatory diagnostic groups. The adjusted R2 value of the retrospective regression models for total approved dollars was 0.42 for both study years when CCHPR categories were used. In contrast, age-sex explanatory variables alone achieved an R2 of 0.02. The CCHPR method appears to be a promising tool to understand variability in physician resource utilization in managed care.

Physician resource utilization in radiation oncology: A model based on management of carcinoma of the prostate

Purpose : To develop a methodology to estimate the comparative cost of physician time in treating patients with localized prostate cancer, using as an example two-dimensional (2D) vs. three-dimensional (3D) conformal irradiation techniques, and to illustrate how current cost-accounting techniques can be used to quantify the cost of physician time and effort of any treatment. Methods and Materials : Activity-based costing, a recent innovation in accounting, widely recommended for estimating and managing the costs of specific activities, was used to derive physician resource utilization costs (actual cost of the physician services and related support services consumed). Results : Patients treated with 3D conformal irradiation consume about 50% more physician time thanpatients receiving 2D conventional radiation therapy. The average professional reimbursement for 3D conformal irradiation is only about 26% more than for the 2D treatment. Substantial variations in cost are found depending on the total available physician working hours. In an academic institution, a physician working 40 hours a week would have to spend an average of about 60% of available time on clinical services to break even on a 2D treatment process and over 74% of available time on clinical work to break even on a 3D treatment process. The same physician working 50 hours a week would have to spend an average of about 48% of available time on 2D clinical sevices and about 60% of available time on 3D clinical work to break even. Current Medicare reimbursement for 3D treatment fall short of actual costs, even if physician work 100% of a 50-hour week. Medicare reimbursement for 2D barely allows the department to break even for 2D treatments. Conclusions : Costs based on estimates of resource use can be substantially under- or overestimated. A consistent language (method) is needed to obtain and describe the costs of radiation therapy. The methodology described here can help practitioners and researchers more accurately interpret actual cost information. Future use of such cost-estimation methodologies could provide consistent and comparable costs for negotiations with health care providers and help assess different treatment strategies.

Physician resource utilization after geriatric trauma.

As health care resources become increasingly strained, the value of physician consultation has come under heightened scrutiny. This report reviews the value of early consultation by the physical medicine and rehabilitation (PMR) service to an integrated trauma service for geriatric patients with multiple trauma. We retrospectively reviewed the records of 110 geriatric trauma patients (age > 60 years) with an Injury Severity Score > or = 15 to evaluate the effects of PMR consultation. Patients in group 1 were admitted to a general surgical service, and those in group 2 were admitted to a multidisciplinary trauma service. Demographic and physiologic factors, as well as short-term and long-term outcomes, were evaluated, and a subgroup analysis was performed to compare early (< or =3 days) versus late (>3 days) consultation by PMR. Although there were significant differences in Glasgow Coma Scale score and length of stay, no differences were found within groups in other demographic, physiologic, or outcome data. Focused review of PMR intervention based on early versus late consultation revealed no significant difference between the two groups. Furthermore, an after-discharge phone survey revealed no significant group differences in dependence on a care provider or nursing home placement, readmission to hospital, employment status, or current functional activity status. Long-term patient functional outcome and the in-house rehabilitation process are not affected by integration of PMR into a multidisciplinary trauma team or early PMR consultation.

Ambulatory care groups and the profiling of primary care physician resource use

A variety of profiling models and tools is utilized by payers, providers, and regulators to evaluate physician work, performance, and resource utilization. In physician profiling, the provider's pattern of practice is expressed as a rate of service or outcome. The article by Tucker, Weiner, Honigfeld, and Parton (this issue) compares the practice-based norms of primary care physicians by adjusting for case mix using ambulatory care groups (ACGs), a population-based classification method. Once the case mix is adjusted, the actual use of resources, as measured by overall charges, is compared with the expected value of resource use. In the Center for Research in Ambulatory Health Care Administration (CRAHCA) Physician Profiling Project, funded by The Robert Wood Johnson Foundation, physicians learn which services other physicians in their specialties perform. Physicians are able to compare their profiles with state and national level medians. The profiling project is one of the first demonstration projects in the field to profile ambulatory care practice patterns and collect patient demographics. An aspect of the project is to test the ACG classification system to data selected from 130 nonacademic practices representing over 5,000 physicians.

791–5 Physician Profiles of Coronary Revascularization in the Emory Angioplasty vs Surgery Trial: Understanding Physician Differences Using Resource-based Relative Values

Understanding the reasons for variations in physician resource utilization in coronary angioplasty (PTCA) and coronary surgery (CABG) is essential to efficiently organizing, managing, and paying for these procedures. To evaluate the extent of variations in physician resource utilization for CABGs and PTCAs and the reasons for these variations, the resource-based relative value scale (RBRVS), an index of relative weights for physician work and practice costs, is used to evaluate physician practice patterns. Given their extensive clinical review, RBRVS weights represent new, unique, comprehensive measures of physician resource utilization where 1 unit value is equivalent to an intermediate office visit for an established patient. Our investigation uses 3 years of clinical and financial data on 392 randomized patients with multivessel coronary artery disease (EAST data). receiving the initial therapy of either CABG or PTCA. RBRVS weights are assigned to each procedure code (CPT) and the distribution of RBRVS units and their allocation among different types of services are analyzed. Results show significant differences in physician resources for both CABGs and PTCAs. Among CABG patients, nearly a ninefold variation in physician resource units is evident (108 ± 46) and, for PTCA, a 29-fold variation exists (66 ± 54). At three years, the average physician resource utilization for CABG is 64% greater than PTCA. Significant differences are also evident in surgical, laboratory, imaging, and consult resources even after accounting for casemix. The findings demonstrate that the RBRVS is a viable and useful analytical tool for managerial and clinical personnel.