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Practice Variability

Physician Variability in Management of Emergency Department Patients with Chest Pain

Peter B. Smulowitz, MD, MPH, et al.

Chest pain is a common emergency department (ED) presentation accounting for 8–10 million visits per year in the United States. Physician-level factors such as risk tolerance are predictive of admission rates. The recent advent of accelerated diagnostic pathways and ED observation units may have an impact in reducing variation in admission rates on the individual physician level.

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Practice Variability

Quality Improvement Initiative to Decrease Variability of Emergency Physician Opioid Analgesic Prescribing

Volume 17, Issue 3, May 2016
John Burton, MD, et al.

Introduction: Addressing pain is a crucial aspect of emergency medicine. Prescription opioids
are commonly prescribed for moderate to severe pain in the emergency department (ED);
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unfortunately, prescribing practices are variable. High variability of opioid prescribing decisions
suggests a lack of consensus and an opportunity to improve care. This quality improvement (QI)
initiative aimed to reduce variability in ED opioid analgesic prescribing.
Methods: We evaluated the impact of a three-part QI initiative on ED opioid prescribing by
physicians at seven sites. Stage 1: Retrospective baseline period (nine months). Stage 2:
Physicians were informed that opioid prescribing information would be prospectively collected and
feedback on their prescribing and that of the group would be shared at the end of the stage (three
months). Stage 3: After physicians received their individual opioid prescribing data with blinded
comparison to the group means (from Stage 2) they were informed that individual prescribing
data would be unblinded and shared with the group after three months. The primary outcome was
variability of the standard error of the mean and standard deviation of the opioid prescribing rate
(defined as number of patients discharged with an opioid divided by total number of discharges
for each provider). Secondary observations included mean quantity of pills per opioid prescription,
and overall frequency of opioid prescribing.
Results: The study group included 47 physicians with 149,884 ED patient encounters. The
variability in prescribing decreased through each stage of the initiative as represented by the
distributions for the opioid prescribing rate: Stage 1 mean 20%; Stage 2 mean 13% (46%
reduction, p<0.01), and Stage 3 mean 8% (60% reduction, p<0.01). The mean quantity of pills
prescribed per prescription was 16 pills in Stage 1, 14 pills in Stage 2 (18% reduction, p<0.01),
and 13 pills in Stage 3 (18% reduction, p<0.01). The group mean prescribing rate also decreased
through each stage: 20% in Stage 1, 13% in Stage 2 (46% reduction, p<0.01), and 8% in Stage
3 (60% reduction, p<0.01).
Conclusion: ED physician opioid prescribing variability can be decreased through the systematic
application of sharing of peer prescribing rates and prescriber specific normative feedback.

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Practice Variability

Clinical Management of Skin and Soft Tissue Infections in the U.S. Emergency Departments

Volume 15, Issue 4, July 2014
Rakesh D. Mistry, MD, MS et al.

Community-associated methicillin resistant Staphylococcus aureus (CA-MRSA) has emerged as the most common cause of skin and soft-tissue infections (SSTI) in the United States. A nearly three-fold increase in SSTI visit rates had been documented in the nation’s emergency departments (ED). The objective of this study was to determine characteristics associated with ED performance of incision and drainage (I+D) and use of adjuvant antibiotics in the management of skin and soft tissue infections (SSTI).

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Practice Variability

Warming Intravenous Fluids for Improved Patient Comfort in the Emergency Department: A Pilot Crossover Randomized Controlled Trial

Author Affiliation Wesley H. Self, MD, MPH  Vanderbilt University School of Medicine, Department of Emergency Medicine, Nashville, Tennessee Steven J. White, MD  Vanderbilt University School of Medicine, Department of Emergency Medicine, Nashville, Tennessee Candace D. McNaughton, MD, MPH  Vanderbilt University School of Medicine, Department of Emergency Medicine, Nashville, Tennessee Alan B. Storrow, MD  Vanderbilt University […]

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Practice Variability

Variation in Specialists’ Reported Hospitalization Practices of Children Sustaining Blunt Abdominal Trauma

Introduction: Children with blunt abdominal trauma (BAT) are often hospitalized despite no intervention. We identified factors associated with emergency department (ED) disposition of children with BAT and differing computed tomography (CT) findings.

Conclusion: Substantial variation exists between specialties in reported hospitalization practices of asymptomatic children after abdominal trauma with minor CT findings. Better evidence is needed to guide disposition decisions.

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Practice Variability

Variation in Specialists’ Reported Hospitalization Practices of Children Sustaining Blunt Head Trauma

Introduction: Questions surround the appropriate emergency department (ED) disposition of children who have sustained blunt head trauma (BHT). Our objective was to identify physician disposition preferences of children with blunt head trauma (BHT) and varying computed tomography (CT) findings.

Conclusion: Substantial variation exists between specialties in reported hospitalization practices of neurologically-normal children with BHT and traumatic CT findings.

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Practice Variability

The Treatment of Cutaneous Abscesses: Comparison of Emergency Medicine Providers’ Practice Patterns

Introduction: Cutaneous abscesses are commonly treated in the emergency department (ED). This study sought to describe the ED treatments administered to adults with uncomplicated superficial cutaneous abscesses, defined as purulent lesions requiring incision and drainage that could be managed in an ED or outpatient setting.

Conclusion:Variability exists in the treatment strategies for abscess care. Most providers used narcotic analgesics in addition to local anesthetic, linear incisions, and packing. Most providers did not irrigate, order wound cultures, or routinely prescribe oral antibiotics unless specific risk factors or physical signs were present.

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Emergency Medicine is a specialty which closely reflects societal challenges and consequences of public policy decisions. The emergency department specifically deals with social injustice, health and economic disparities, violence, substance abuse, and disaster preparedness and response. This journal focuses on how emergency care affects the health of the community and population, and conversely, how these societal challenges affect the composition of the patient population who seek care in the emergency department. The development of better systems to provide emergency care, including technology solutions, is critical to enhancing population health.