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Original research
What determines diagnostic resource consumption in emergency medicine: patients, physicians or context?
  1. Wolf E Hautz1,2,
  2. Thomas C Sauter1,3,
  3. Stephanie C Hautz1,
  4. Juliane E Kämmer4,5,
  5. Stefan K Schauber2,6,
  6. Tanja Birrenbach1,
  7. Aristomenis K Exadaktylos1,
  8. Stephanie Stock7,
  9. Martin Müller1,7
  1. 1Department of Emergency Medicine, Inselspital Berne, Bern, Switzerland
  2. 2Center for Educational Measurement, University of Oslo, Oslo, Norway
  3. 3Medical Skills Lab, Charité Universitätsmedizin Berlin, Berlin, Germany
  4. 4Center for Adaptive Rationality, Max-Planck-Institut fur Bildungsforschung, Berlin, Germany
  5. 5Institute of Health and Nursing Science, Charité Universitätsmedizin Berlin, Berlin, Germany
  6. 6Faculty of Medicine, University of Oslo, Oslo, Norway
  7. 7Institute of Health Economics and Clinical Epidemiology, University Hospital of Cologne, Cologne, Germany
  1. Correspondence to Dr Martin Müller, Department of Emergency Medicine, Inselspital Universitatsspital Bern, Bern 3010, Switzerland; martin.mueller2{at}insel.ch

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.

  • emergency care systems
  • diagnosis
  • clinical management

Data availability statement

Data are available upon reasonable request. The data used to support the findings of this study are available from the corresponding author upon request for researchers eligible to work with codified health data under Swiss legislation. Eligibility will be determined by the ethics committee.

http://creativecommons.org/licenses/by-nc/4.0/

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/.

https://doi.org/10.1136/emermed-2019-209022

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    Data availability statement

    Data are available upon reasonable request. The data used to support the findings of this study are available from the corresponding author upon request for researchers eligible to work with codified health data under Swiss legislation. Eligibility will be determined by the ethics committee.

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    Footnotes

    • Handling editor Richard Body

    • Contributors All authors contributed to the conception of the study, analysis and interpretation of the results and the final approval of the manuscript. Study design: MM, WEH, SS. Data analysis: MM, SKS. Drafting the manuscript: WEH, MM. Critical revision of the manuscript for intellectual content: WEH, TCS, SCH, JEK, SKS, TB, AE, SS, MM.

    • Funding MM was funded by the Bangarter Foundation and the Swiss Academy of Medical Sciences through the 'Young Talents in Clinical Research' grant (TCR 14/17) as well as through a CTU grant of Inselgruppe.

    • Competing interests WEH received speaker honorariums from the AO Foundation in Zurich and research funding from Mundipharma Medical Basel. TCS has received research grants or lecture fees from Bayer, Boehringer Ingelheim and Daiichi-Sankyo and the Gottfried and Julia Bangerter-Rhyner Foundation.

    • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.