Browsing by keyword "variation"
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Analysis of Consistency in Emergency Department Physician Variation in Propensity for Admission Across Patient Sociodemographic GroupsImportance: Sociodemographic disparities in health care and variation in physician practice patterns have been well documented; however, the contribution of variation in individual physician care practices to health disparities is challenging to quantify. Emergency department (ED) physicians vary in their propensity to admit patients. The consistency of this variation across sociodemographic groups may help determine whether physician-specific factors are associated with care differences between patient groups. Objective: To estimate the consistency of ED physician admission propensities across categories of patient sex, race and ethnicity, and Medicaid enrollment. Design, Setting, and Participants: This cross-sectional study analyzed Medicare fee-for-service claims for ED visits from January 1, 2016, to December 31, 2019, in a 10% random sample of hospitals. The allocation of patients to ED physicians in the acute care setting was used to isolate physician-level variation in admission rates that reflects variation in physician decision-making. Multi-level models with physician random effects and hospital fixed effects were used to estimate the within-hospital physician variation in admission propensity for different patient sociodemographic subgroups and the covariation in these propensities between subgroups (consistency), adjusting for primary diagnosis and comorbidities. Main Outcomes and Measures: Admission from the ED. Results: The analysis included 4567760 ED visits involving 2334361 beneficiaries and 15767 physicians in 396 EDs. The mean (SD) age of the beneficiaries was 78 (8.2) years, 2700661 visits (59.1%) were by women, and most patients (3839055 [84.1%]) were not eligible for Medicaid. Of 4 473 978 race and ethnicity reports on enrollment, 103 699 patients (2.3%) were Asian/Pacific Islander, 421 588 (9.4%) were Black, 257 422 (5.8%) were Hispanic, and 3 691 269 (82.5%) were non-Hispanic White. Within hospitals, adjusted rates of admission were higher for men (36.8%; 95% CI, 36.8%-36.9%) than for women (33.7%; 95% CI, 33.7%-33.8%); higher for non-Hispanic White (36.0%; 95% CI, 35.9%-36.0%) than for Asian/Pacific Islander (33.6%; 95% CI, 33.3%-33.9%), Black (30.2%; 95% CI, 30.0%-30.3%), or Hispanic (31.1%; 95% CI, 30.9%-31.2%) beneficiaries; and higher for beneficiaries dually enrolled in Medicaid (36.3%; 95% CI, 36.2%-36.5%) than for those who were not (34.7%; 95% CI, 34.7%-34.8%). Within hospitals, physicians varied in the percentage of patients admitted, ranging from 22.4% for physicians at the 10th percentile to 47.6% for physicians at the 90th percentile of the estimated distribution. Physician admission propensities were correlated between men and women (r = 0.99), Black and non-Hispanic White patients (r = 0.98), and patients who were dually enrolled and not dually enrolled in Medicaid (r = 0.98). Conclusions and Relevance: This cross-sectional study indicated that, although overall rates of admission differ systematically by patient sociodemographic factors, an individual physician's propensity to admit relative to other physicians appears to be applied consistently across sociodemographic groups of patients.
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Geographic Variation in Hospital Costs Associated with Isolated Coronary Artery Bypass GraftingBackground: In the past decades, studies have shown geographic variation (GV) in patient risk factors, outcomes, and practice patterns associated with coronary artery bypass grafting (CABG). However, contemporary data related to GV in hospital costs associated with isolated CABG are lacking. Methods: We used the latest (2014) National Inpatient Sample (NIS) to identify patients aged 18+ who underwent primary isolated CABG. ICD-9 codes were used to derive comorbidities and procedure types. Geographic stratification was based on the Census Division of each hospital. The NIS cost-to-charge ratio based on all-payer inpatient costs and census-region-based medical care consumer price index were used to adjust for hospital costs. Data were analyzed by using weighted analyses of variance for continuous data and the Rao-Scott likelihood ratio Chi-square test for categorical variables. Weighted multivariable regression analysis was used to examine the association between geographic divisions and adjusted costs (log-transformed) by adjusting for patient/procedure characteristics, and comorbidities. Results: In 2014, 132,270 patients from 1,106 hospitals underwent a primary isolated CABG. The median (Inter Quartile Range [IQR]) of age was 65 (57-72) years (GV: 63-66), and 25% was female (GV: 22%-28%). Overall, 47% were admitted electively (GV: 38%-54%), 28% had a primary diagnosis of acute myocardial infarction (GV: 26%-32%), 84% had hypertension (GV: 80%-86%), 27% had atrial fibrillation (GV: 24%-29%), 12% (GV: 8%-15%) had 4+ coronary arteries bypassed and 1.4% died in-hospital (GV: 0.9%-2.1%). The median (IQR) hospital length of stay was 6.9 (5.0-9.8) days (GV: 6.3-7.2). The median (IQR) adjusted cost was $34,949 ($26,879-$44,725), which was lowest in the East South Central ($28,854 [$23,268-$36,193]) and highest in the East North Central ($41,852 [$32,965-$54,223]) (p Conclusions: We observed statistically, but not clinically, significant differences in patient baseline characteristics. Geographic variations exist in outcomes and the hospital costs among patients who underwent isolated CABG.

