Original Investigation
December 23, 2024
Variation in Emergency Department Physician Admitting Practices and Subsequent Mortality
Stephen Coussens, Dan P. Ly
JAMA Intern Med. Published online December 23, 2024. doi:10.1001/jamainternmed.2024.6925
Question By how much does the propensity to admit patients vary across physicians within a given emergency department (ED), and do higher admission propensities result in lower patient mortality?
Findings In this cross-sectional study using electronic health record data from more than 2 million ED visits treated by 2098 physicians across 105 EDs, being treated by a physician with an admission propensity at the 90th percentile relative to a physician at the 10th percentile nearly doubled a patient’s probability of being admitted to the hospital but did not reduce their subsequent mortality rate.
Meaning Higher admission propensities do not appear to reduce patient mortality.
Abstract
Importance An emergency department (ED) physician’s decision to admit a patient to the hospital plays a pivotal role in determining the type and intensity of care that patient will receive. ED physicians vary widely in their propensity to admit patients to the hospital, but it is unknown whether higher admission propensities result in lower subsequent mortality rates.
Objective To measure the variation in ED physicians’ admission propensities and estimate their association with patients’ subsequent mortality rates.
Design, Setting, and Participants This cross-sectional study used nationwide Veterans Affairs electronic health record data from January 2011 to December 2019, comparing physicians practicing within the same ED. The study population was composed of patients visiting the ED with 1 of the 3 most frequent chief complaints in US EDs (chest pain, shortness of breath, and abdominal pain). The data analyses were performed from May 2022 to October 2024.
Main Outcomes and Measures The main outcomes were variation in physicians’ adjusted admission rates, short inpatient stays (<24 hours), and 30-day mortality.
Results The study population included 2098 physicians seeing 2 137 681 patient visits across 105 EDs. The mean (SD) patient age was 63 (15) years, and 9.8% of patients were female. The mean admission rate was 41.2%, and the mean 30-day mortality rate was 2.5%. Physicians’ adjusted admission rates varied greatly within the same ED (eg, for chest pain: 90th percentile of physicians, 56.6% admitted vs 10th percentile, 32.6% admitted; difference, 24.0 percentage points), despite finding no association between these adjusted admission rates and patients’ prior health status as measured by their Elixhauser Comorbidity Index score before the ED visit. However, patients admitted by physicians with higher admission rates were more likely to be discharged within 24 hours (eg, 31.0% vs 24.8%, respectively), while patients of physicians with higher admission rates had subsequent mortality rates that were no less than those of patients of physicians with lower admission rates.
Conclusions and Relevance This cross-sectional study demonstrated that ED physicians vary widely in their admission propensity, despite seeing patients with similar prior health status. The results suggest that patients treated by physicians with higher admission propensities are more likely to be discharged after only a short inpatient stay and experience no reduction in subsequent mortality rates.
