Patient Care

Emergency Department Utilization May Be Lower for Attending-Only Physician Visits versus Supervised Visits


Clinical question: Does supervised learning in the ED lead to higher rates of resource utilization?

Background: Care at academic medical centers might be more expensive than nonteaching hospitals because of the increased testing and resource utilization that occurs among learners. Although there is a growing emphasis in training programs on cost-conscious care, little data has looked at resource use as an outcome.

Study design: Cross-sectional study of the National Hospital Ambulatory Medical Care Survey in 2010.

Setting: Probability sample of American EDs and ED visits.

Synopsis: Using the 2010 National Hospital Ambulatory Medical Care Survey ED sub-file, a probability sample of 29,182 ED visits was obtained—25,808 attending-only visits and 3,374 supervised visits.

Supervised visits were more likely to lead to hospital admissions (21% versus 14%), advanced imaging (28% vs. 21%), and a longer median ED stay, but not with more blood testing than attending-only ED visits. EDs were placed into three categories: “nonteaching”; “minor teaching,” where trainees are involved in fewer than 50% of visits; and “major teaching,” where trainees are involved in more than 50% of visits. Study results showed no increase in resource utilization in major teaching EDs, except for an increase in ED length of stay.

Although there was an attempt to adjust for biased selection and complexity, there is a risk that biased selection of “teaching cases” in minor teaching EDs could explain some of the higher resource use for these cases. This study does not imply causation; however, it suggests that further studies might be warranted to evaluate the relationship between learners and resource utilization.

Bottom line: Supervised visits were associated with increased hospital admissions, advanced imaging, and longer ED length of stay (LOS), but other than LOS, this relationship did not persist in major teaching EDs.

Citation: Pitts SR, Morgan SR, Schrager JD, Berger TJ. Emergency department resource use by supervised residents vs attending physicians alone. JAMA. 2014;312(22):2394-2400.

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