Using Physician-Level Emergency Department Utilization Reports to Address Avoidable Visits by Patients Managed by Pediatric Specialists
OBJECTIVES: Emergency department (ED) utilization is a major driver of cost. Specialist physicians have an important role in addressing ED utilization, especially at tertiary medical centers that treat highly specialized patients. We analyzed if reporting of ED utilization to pediatric specialist physicians can decrease ED visits.
METHODS: Physicians within pediatric neurology, hematology and oncology, infectious diseases, and pulmonary divisions received their ED use reports. By using control charts, we examined if this intervention decreased the rate of ED utilization.
RESULTS: Overall, for the 4 divisions, specialty-related ED utilization decreased significantly during all hours, weekdays, and office hours. This was in the setting of ED utilization increasing for all diagnoses ED visits. Pediatric ED volume did not change during the study period.
CONCLUSIONS: Physician-level reporting of ED utilization was associated with a reduction in ED use by patients managed by our pediatric specialists.
Emergency department (ED) visits account for a significant proportion of health care costs. Previous estimates reveal that 13.7% to 27.1% of ED visits could potentially be provided at alternative sites, resulting in significant health care savings.1,2 Our group recently published results of the use of a physician-level report on ED use by patients seen by pediatric gastroenterologists, which resulted in a significant and sustained decrease in ED utilization over a 2-year period.3 Subsequently, we have expanded the project to the following pediatric divisions: (1) neurology; (2) hematology and oncology; (3) infectious diseases; and (4) pulmonary. In this study, we evaluate if reporting of ED utilization decreases the rate of specialty-related ED visits by patients managed by these pediatric specialists.
Study Design, Setting, and Intervention
We analyzed data that was retrospectively collected to reduce ED utilization by pediatric patients who had completed outpatient visits in the following pediatric specialist practices: neurology, hematology and oncology, infectious diseases, and pulmonary. The project was conducted at a tertiary-care referral hospital in a major urban city. This study was exempted by the hospital’s institutional review board.
Between August 2014 and November 2015, our pediatric specialists began receiving reports with rates of ED utilization by their patients. Two separate reports were distributed: (1) 1 individualized to the physician; and (2) 1 with all physician rates for the divisional leadership.
Our department of pediatrics made reducing ED utilization by patients managed by the pediatric specialists a priority. To engage the pediatric divisions, we used the physician organization’s financial incentive program to have the divisions review and discuss the reports.4,5 To receive the financial bonus, each division chief first received an introduction to the project. Next, we presented the project and disseminated individual reports to the physicians at a staff meeting. On the basis of the reports, the physicians then discussed potential interventions to reduce ED use by their patients. The divisions received follow-up reports every 6 months.
In terms of specific interventions, this was left up to the divisions. The majority of the divisions did not have a specific intervention: neurology, hematology and oncology, and infectious disease. On the basis of their data, our pediatric pulmonologists implemented a call-back program in which their nurse would call high-risk patients after discharge from the hospital.
Description of Reports
The reports contained only patients who were seen in the ED and discharged from the hospital, excluding those who required admission to the hospital or to observation. The reports included both all-cause ED visits and specialty-related ED visits. For both all-cause and specialty-related utilization, rates were calculated for ED visits during (1) all hours of the day, (2) weekdays, and (3) office hours.
We defined a specialty-related ED visit by using the primary diagnosis on discharge from the ED. On the basis of the International Classification of Diseases, Ninth Revision code of the primary diagnosis, we applied a diagnosis categorization tool that clusters patient diagnoses (Clinical Classifications Software for ICD-9; Agency for Healthcare Research and Quality, Rockville, MD).
Individual physician reports included the medical record number, patient name, ED diagnosis, and whether the patient was seen during a weekday (all hours) or office hours. A visit was deemed as being during office hours if the time of presentation was between 9 am and 5 pm on Monday through Friday.
Study Population and Data Collection
For each report, we identified all eligible ED visits from hospital databases for a 12-month period immediately before disseminating the reports. A dedicated hospital analyst pulled the data into Excel documents, which were then made into the reports. Eligible visits concluded with discharge from the ED for a patient who had seen a pediatric specialist in the office within the previous 12 months. Specific data elements included patient name, medical record number, name of pediatric specialist, date of last office visit to a pediatric specialist, ED visit date and time, ED visit disposition location, primary diagnosis in ED, and secondary diagnosis in ED.
The primary outcome was the mean rate of specialty-related ED visits for the division before and after the start of physician-level reporting during office hours. The following rates of ED visits were calculated for each physician, as well as for each pediatric specialty division: (1) ED visits during all hours of the day for all-diagnoses; (2) ED visits during all hours of the day for specialty-related diagnoses; (3) ED visits during office hours for specialty-related diagnoses; and (4) ED visits during weekdays for specialty-related diagnoses.
To see if the decreased ED volume was related to a change in overall ED volume, we also examined the total pediatric ED volume during the study period from May 2014 to December 2016.
Calculation of Rates
The numerator was the total number of attributable ED visits for that category and the denominator was the total number of office visits seen in outpatient practice by the physician over a 12-month period. All rates were defined as per 1000 office visits.
To analyze the impact of the intervention on rates of ED utilization, we used control charts with upper and lower control limits set at 3 σ. Specifically, we used u-charts because the denominator changed during the study period. For analyzing the pediatric ED volume, we used a run chart. Special cause variation was determined by previously published criteria and shown as red points on the control charts.6 We used SPSS Version 22.0 (IBM Corp, Armonk, NY) and Microsoft Excel 2016 (Microsoft Corp, Redmond, WA) with the QIMacros add-in (KnowWare International, Inc, Denver, CO).
Specialty-Specific ED Utilization During All Hours
Before the intervention, there was an overall higher rate of specialty-specific ED utilization as shown by special cause variation before the intervention in Fig 1. After the intervention, there was an overall decrease in ED utilization by patients managed by the 4 divisions. Immediately after the intervention, there was common cause variation in ED utilization until April of 2016. Starting April 2016, there was a decrease of 5 points below the 1 σ threshold, consistent with special cause variation.7
Specialty-Specific ED Utilization During Weekdays
Similarly, specialty-specific ED utilization during weekdays was consistently high before the intervention and decreased significantly starting around April 2016. The effect was sustained through December 2016 (Fig 2).
Specialty-Specific ED Utilization During Office Hours
Specialty-specific ED utilization during office hours also decreased after the intervention with a special cause variation decrease between April 2016 to August 2016 (Fig 3).
Overall Pediatric ED Volume
Between May 2014 and December 2016, the pediatric ED volume stayed consistent with a mean of 1177 ED visits per month. The special cause variations in the control chart reflect the regular peaks and troughs of pediatric ED volume during different seasons.
As further sensitivity analysis revealed, all diagnoses ED utilization during all hours increased during the study period (Fig 4). These are patients who were attributed to the pediatric specialists and went to the ED for all reasons, and not just for reasons related to the specialty. Overall, ED utilization increased steadily during the study period, with a special cause variation increase starting April 2016.
We found a decrease in ED use by patients managed by the 4 pediatric specialty practices of neurology, hematology and oncology, infectious diseases, and pulmonary. The decrease in specialty-related ED visits was noted to occur a few months after our initial intervention. This was in the setting of an overall increase in use of the ED by the patients managed by our 4 pediatric specialties. Our results demonstrate that using simple and low-cost reporting of ED utilization rates can result in decrease in ED utilization by specialty pediatric practices. The primary intervention in these 4 groups was reporting of aggregate and individual physician-level data with regular intervals of follow-up data. These findings are congruent with our experience with pediatric gastroenterology.3
The results are also in the setting of an unchanged mean in total pediatric ED volume during the study period. We did not expect the overall ED volume to decrease, especially because the absolute number of ED cases decreased by our intervention is small compared with the total ED volume. Instead, we used the ED volume as a surrogate to show that the acute care volume for pediatrics was unchanged and did not contribute to the overall decrease in ED visits by the 4 divisions.
Authors of other studies have found that better continuity of care among pediatric patients reduces ED utilization, especially among those with chronic conditions.8–10 Furthermore, Patel et al11 recently found a significant reduction in ED utilization by children with epilepsy after implementing a focused and well-thought-out intervention. As a result, pediatric patients could benefit from interventions that target specialized populations with chronic conditions, particularly those managed by tertiary specialty practices. Engaging specialists at these tertiary centers could decrease ED utilization and result in improved patient satisfaction, cost savings, ED length-of-stay, and patient retention.
Engagement of Pediatric Specialists
Interestingly, our results reveal that even without a defined intervention in some of the departments, the rates of ED utilization decreased just with reporting and focusing on the problem. For the reports to be effective, we felt that the data should provide our pediatric physicians with data regarding potentially avoidable ED visits. With this in mind, we decided to include the following domains in the physician reports: (1) provide only data and rates on patients who were seen in the ED and discharged from the hospital; (2) data and rates of patients seen in the ED during office hours; and (3) rates of specialty-related ED visits. The last component was important because most specialist physicians would not be able to impact ED visits for diagnoses that were unrelated to their specialty.
Specialized Patient Populations and Tertiary Medical Centers
Previous studies have revealed that better continuity of care among pediatric patients result in decreased ED utilization, especially among patients with chronic conditions.8–10,12 As a result, pediatric patients could benefit from interventions that target specialized populations with chronic conditions, such as ones followed by highly specialized tertiary centers. Engaging specialists at these tertiary referral centers could potentially decrease ED utilization and ultimately lead to improved patient satisfaction, cost savings, length-of-stay, and patient retention.
New Payment Models and Specialists
As our nation’s decision makers continue to debate and modify how health care is financed and delivered in the United States, the burden of improving patient outcomes and reducing costs will continue to shift more and more to the hospitals and systems taking care of patients on a daily basis. As such, we will need more innovative and low-cost initiatives to further improve care and decrease costs. We believe that our intervention can potentially help, especially at large tertiary medical centers with complex patient populations.
There are limitations to our study. First, the retrospective analysis of the hospital data set allows us to describe only associations. Second, our results were from 1 tertiary urban center and might not apply to other settings.
Our results revealed that physician-level reporting of ED utilization to pediatric specialists was associated with a decrease in use of the ED by neurology, hematology and oncology, infectious diseases, and pulmonary patients.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
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- Copyright © 2017 by the American Academy of Pediatrics