Does the Physician Matter?

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Hospitalizations account for the largest share of health care spending in the United States. There are approximately 9 million hospital admissions originating from the emergency department (ED) for people aged 65 or over each year. The decision to admit these patients falls to their attending ED physician. These admission rates vary widely not only across the country, but also across hospitals as well.  

In a study published in Health Affairs, department of health care policy statistician III Lawrence Zaborski, MS, Warren Alpert Foundation Professor of Health Care Policy J. Michael McWilliams, MD, PhD, professor of health care policy Bruce Landon, MD, MBA, and colleagues examine variation in ED admission rates between physicians in the same hospital to identify if some physicians admit more than others, and if specific patient characteristics lead to higher physician-level admission rates.

Examining Medicare fee-for-service claims for a random sample of beneficiaries from January 2012 through September 2015, the investigation uncovered meaningful variation in admission rates between ED physicians in the same hospital. The study found that the mean physician-level admission rate was 38.9%, ranging from 32.2% to 45.6 % for physicians within the same hospital.

The majority of ED patients do not select their physician, meaning that ED physicians are naturally randomly assigned. The study found that physicians’ decision to admit was unrelated to patient characteristics, with moderate-to-high correlation in physician-level admission rates across clinical conditions.

“This focus has a clear policy relevance, as it points to an actionable area for interventions aimed at altering admission rates by modifying physician behavior,” The authors state, “That there is significant variation among physicians even within the same hospital suggests that there is an opportunity to devise interventions targeted at physician decision making.”

Understanding physician decision making is a necessary step towards reducing unnecessary hospital admissions from the ED and their associated costs. The authors suggest interventions such as clinical pathways for specific conditions or feedback of physician admission metrics to better support ED physician decision making.