Reliability of a Measure of Admission Intensity for Emergency Physicians - 02/03/24

Doi : 10.1016/j.annemergmed.2024.02.002

Alexander T. Janke, MD, MHS ^a,^b,^⁎ , Jonathan J. Oskvarek, MD, MBA ^c,^d, Mark S. Zocchi, PhD, MPH ^c,^e, Angela G. Cai, MD, MBA ^f, Ori Litvak, MBA ^g, Jesse M. Pines, MD, MBA ^c, Arjun K. Venkatesh, MD, MBA ^b
^a VA HSR&D Center for the Study of Healthcare Innovation, Implementation, & Policy/Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
^b Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
^c US Acute Care Solutions, Canton, OH
^d Department of Emergency Medicine, Summa Health System, Akron, OH
^e Heller School for Social Policy and Management, Braindeis University, Waltham, MA
^f Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
^g LogixHealth, Bedford, MA

^∗Corresponding Author.

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Abstract

Study objective

We assess the stability of a measure of emergency department (ED) admission intensity for value-based care programs designed to reduce variation in ED admission rates. Measure stability is important to accurately assess admission rates across sites and among physicians.

Methods

We sampled data from 358 EDs in 41 states (January 2018 to December 2021), separate from sites where the measure was derived. The measure is the ED admission rate per 100 ED visits for 16 clinical conditions and 535 included International Classification of Disease 10 diagnosis codes. We used descriptive plots and multilevel linear probability models to assess stability over time across EDs and among physicians.

Results

Across included 3,571 ED-quarters, the average admission rate was 27.6% (95% confidence interval [CI] 26.0% to 28.2%). The between-facility standard deviation was 9.7% (95% CI 9.0% to 10.6%), and the within-facility standard deviation was 3.0% (95% CI 2.95% to 3.10%), with an intraclass correlation coefficient of 0.91. At the physician-quarter level, the average admission rate was 28.3% (95% CI 28.0% to 28.5%) among 7,002 physicians. Relative to their site’s mean in each quarter, the between-physician standard deviation was 6.7% (95% CI 6.6% to 6.8%), and the within-physician standard deviation was 5.5% (95% CI 5.5% to 5.6%), with an intraclass correlation coefficient of 0.59. Moreover, 2.9% of physicians were high-admitting in 80%+ of their practice quarters relative to their peers in the same ED and in the same quarter, whereas 3.9% were low-admitting.

Conclusion

The measure exhibits stability in characterizing ED-level admission rates and reliably identifies high- and low-admitting physicians.

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Plan

Introduction

Background

Importance

Goals of This Investigation

	Supervising editor: Donald M. Yealy, MD. Specific detailed information about possible conflicts of interest for individual editors is available at editors.
	Author contributions: ATJ, JMP, and AKV conceived the study. OL obtained the data. ATJ, JJO, and MSZ performed the analyses. ATJ drafted the manuscript, and all authors contributed substantially to its revision. ATJ takes responsibility for the manuscript as a whole.
	Data sharing statement: Data are drawn from a national emergency care revenue cycle management company through a data use agreement with Yale University and contain protected health information. They are not available for dissemination.
	All authors attest to meeting the four ICMJE.org authorship criteria: (1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND (2) Drafting the work or revising it critically for important intellectual content; AND (3) Final approval of the version to be published; AND (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
	Funding and support: By Annals’ policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org/). Dr. Janke is supported by the Department of Veterans Affairs Office of Academic Affiliation. Dr. Pines reports consulting unrelated to the submitted work for CSL Behring, Medtronic, and Abbott Point-of-Care. Dr. Venkatesh reports receiving support from the Centers for Medicare and Medicaid Services for the development of hospital and health system outcome measures and quality rating systems. He also reports committee service to American College of Emergency Physicians responsible for the development of emergency physician quality measures including separate measures focused on emergency department admission. The authors report this article did not receive any outside funding or support.
	Disclaimer: The views expressed here do not represent the US government.
	Please see page XX for the Editor’s Capsule Summary of this article.