MP025: Does your patient really need intravenous therapy? A multicenter variation analysis of physician practice in low-acuity presentations

Abstract

Introduction: The decision to treat with parenteral therapy may reflect a variable practice pattern among emergency physicians and represent an opportunity to standardize care. Our objective was to describe physician level practice variation for IV therapies in patients with low-acuity presentations and quantify the contribution of IV therapy to prolonging ED LOS. Methods: Using administrative data merged with computerized physician order entry information we sampled 48 months of patient variables across four urban EDs (Jan 1, 2014 - Dec 22, 2015). Eligible patients: 1. presented with complaints of abdominal pain, nausea and vomiting or diarrhea or had a discharge diagnosis of cellulitis 2.were in a low acuity category (Canadian Triage and Acuity Scale - CTAS 3 or 4) 3.were triaged to non-stretcher zones of the ED and 4.were not admitted to hospital. The primary outcome was the physician-level variation in the decision to order IV therapies for this patient group; namely one or more of the following: IV fluids, opioid analgesia, anti-emetics and antibiotics. Secondary outcomes were a comparison of ED LOS, ED revisits at 7 days and ED revisits resulting in admission at 7 days for the IV and non-IV groups. Results: Our analysis included 31 802 patient visits treated by 185 physicians. The average patient age was 37.8 years with 64.3% being female and the majority triaged as CTAS 3 (82.5%). On average 24% of these visits were treated with IV therapies; 90^th percentile; 34%. For physicians seeing in excess of 100 cases, the variation in IV therapy use ranged from 1% to 47%. Patients receiving IV therapies demonstrated a 44% greater average LOS (6.2 hours vs 4.3 hours) and those receiving IV therapies had higher 7-day ED revisit rates (12.0% vs 8.8%) as well as 7-day ED revisits resulting in readmission (2.4% vs 1.0%). 'mso-spacerun:yes'> Secondary outcomes were a comparison of ED LOS, ED revisits at 7 days and ED revisits resulting in admission at 7 days for the IV and non-IV groups. Conclusion: This is the first study to examine physician preference for the use of IV therapies in a low-acuity population and has demonstrated in excess of a 47-fold variation between both extremes of use. Reducing practice variation in this area of ED care by standardizing indications for IV therapies could result in more rational resource utilization and improved throughput.