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      What determines diagnostic resource consumption in emergency medicine: patients, physicians or context?

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          Abstract

          Objectives

          A major cause for concern about increasing ED visits is that ED care is expensive. Recent research suggests that ED resource consumption is affected by patients’ health status, varies between physicians and is context dependent. The aim of this study is to determine the relative proportion of characteristics of the patient, the physician and the context that contribute to ED resource consumption.

          Methods

          Data on patients, physicians and the context were obtained in a prospective observational cohort study of patients hospitalised to an internal medicine ward through the ED of the University Hospital Bern, Switzerland, between August and December 2015. Diagnostic resource consumption in the ED was modelled through a multilevel mixed effects linear regression.

          Results

          In total, 473 eligible patients seen by one of 38 physicians were included in the study. Diagnostic resource consumption heavily depends on physicians’ ratings of case difficulty (p<0.001, z-standardised regression coefficient: 147.5, 95% CI 87.3 to 207.7) and—less surprising—on patients’ acuity (p<0.001, 126.0, 95% CI 65.5 to 186.6). Neither the physician per se, nor their experience, the patients’ chronic health status or the context seems to have a measurable impact (all p>0.05).

          Conclusions

          Diagnostic resource consumption in the ED is heavily affected by physicians’ situational confidence. Whether we should aim at altering physician confidence ultimately depends on its calibration with accuracy.

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          Most cited references 24

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          Our stubborn quest for diagnostic certainty. A cause of excessive testing.

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            Increased health care costs associated with ED overcrowding.

            The overcrowding of emergency departments (EDs) with inpatients results in an increased average inpatient length of stay; therefore, overcrowded hospitals have increased costs per patient. All admissions through the ED to our institution for 1988, 1989, and 1990 were reviewed. These admissions were analyzed based on whether they had spent less than 1 day or more than 1 day in the ED, after they had been admitted to the hospital and were waiting for a bed assignment. Analyses were performed for the five medical diagnosis-related groups, with the highest volumes of admissions via the ED. All categories were reviewed on the basis of whether or not the payor was Medicare. This was a retrospective data analysis of 3 years worth of hospital and ED length of stay. There was no intervention. The total number of patients admitted via the ED for 1988, 1989, and 1990 was 26,020. In 1988, 19% of admissions via the ED spent more than 1 day in the ED. The total hospital length of stay for this 19% was 11% longer than for the group who reached an inpatient bed on the first hospital day. In 1989, 32% of admissions via the ED remained in the ED for more than 1 day and had a 13% increase in total hospital length of stay. In 1990, 25% of admissions via the ED spent more than 1 day in the ED and had a 10% increase in total hospital length of stay. Inpatients who remained in the ED after admission had a greater average length of stay than those who were promptly transferred to inpatient units.(ABSTRACT TRUNCATED AT 250 WORDS)
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              Emergency Department Utilization by Older Adults: a Descriptive Study

              Background Emergency Departments (EDs) are playing an increasingly important role in the care of older adults. Characterizing ED usage will facilitate the planning for care delivery more suited to the complex health needs of this population. Methods In this retrospective cross-sectional study, administrative and clinical data were extracted from four study sites. Visits for patients aged 65 years or older were characterized using standard descriptive statistics. Results We analyzed 34,454 ED visits by older adults, accounting for 21.8% of the total ED visits for our study time period. Overall, 74.2% of patient visits were triaged as urgent or emergent. Almost half (49.8%) of visits involved diagnostic imaging, 62.1% involved lab work, and 30.8% involved consultation with hospital services. The most common ED diagnoses were symptom- or injury-related (25.0%, 17.1%. respectively). Length of stay increased with age group (Mann-Whitney U; p < .0001), as did the proportion of visits involving diagnostic testing and consultation (χ2; p < .0001). Approximately 20% of older adults in our study population were admitted to hospital following their ED visit. Conclusions Older adults have distinct patterns of ED use. ED resource use intensity increases with age. These patterns may be used to target future interventions involving alternative care for older adults.
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                Author and article information

                Journal
                Emerg Med J
                Emerg Med J
                emermed
                emj
                Emergency Medicine Journal : EMJ
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                1472-0205
                1472-0213
                September 2020
                9 July 2020
                : 37
                : 9
                : 546-551
                Affiliations
                [1 ] departmentDepartment of Emergency Medicine , Inselspital Berne , Bern, Switzerland
                [2 ] departmentCenter for Educational Measurement , University of Oslo , Oslo, Norway
                [3 ] departmentMedical Skills Lab , Charité Universitätsmedizin Berlin , Berlin, Germany
                [4 ] departmentCenter for Adaptive Rationality , Max-Planck-Institut fur Bildungsforschung , Berlin, Germany
                [5 ] departmentInstitute of Health and Nursing Science , Charité Universitätsmedizin Berlin , Berlin, Germany
                [6 ] departmentFaculty of Medicine , University of Oslo , Oslo, Norway
                [7 ] departmentInstitute of Health Economics and Clinical Epidemiology , Cologne , University Hospital of Cologne, Cologne
                Author notes
                [Correspondence to ] Dr Martin Müller, Department of Emergency Medicine, Inselspital Universitatsspital Bern, Bern 3010, Switzerland; martin.mueller2@ 123456insel.ch
                Article
                emermed-2019-209022
                10.1136/emermed-2019-209022
                7497575
                32647026
                © Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

                This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/.

                Product
                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/501100008485, Schweizerische Akademie der Medizinischen Wissenschaften;
                Award ID: YTCR 14/17
                Categories
                Original Research
                1506
                Custom metadata
                unlocked

                Emergency medicine & Trauma

                clinical management, diagnosis, emergency care systems

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