Hodgson, Nicole

AbstractObjectivesTo examine heterogeneity in physician batch ordering practices and measure the associations between a physician's tendency to batch order imaging tests on patient outcomes and resource utilization.Study Setting and DesignIn this retrospective study, we used comprehensive EMR data from patients who visited the Mayo Clinic of Arizona Emergency Department (ED) between October 6, 2018 and December 31, 2019. Primary outcomes are patient length of stay (LOS) in the ED, number of diagnostic imaging tests ordered during a patient encounter, and patients' return with admission to the ED within 72 h. The association between outcomes and physician batch tendency was measured using a multivariable linear regression controlling for various covariates.Data Sources and Analytic SampleThe Mayo Clinic of Arizona Emergency Department recorded approximately 50,836 visits, all randomly assigned to physicians during the study period. After excluding rare complaints, we were left with an analytical sample of 43,299 patient encounters.Principal FindingsFindings show that having a physician with a batch tendency 1 standard deviation (SD) greater than the average physician was associated with a 4.5% increase in ED LOS (p < 0.001). It was also associated with a 14.8% (0.2 percentage points) decrease in the probability of a 72‐h return with admission (p < 0.001), implying that batching may lead to more comprehensive evaluations, reducing the need for short‐term revisits. A batch tendency 1SD greater than that of the average physician was also associated with an additional 8 imaging tests ordered per 100 patient encounters (p < 0.001), suggesting that batch ordering may be leading to tests that would not have been otherwise ordered had the physician waited for the results from one test before placing their next order.ConclusionsThis study highlights the considerable impact of physicians' diagnostic test ordering strategies on ED efficiency and patient care. The results also highlight the need to develop guidelines to optimize ED test ordering practices.

Introduction: Clue cells result from aberrant vaginal microflora and are associated with an increased vaginal pH, which can allow colonization of uropathogens in the vaginal introitus, increasing the risk for urinary tract infections (UTI). We sought to determine whether clue cells on vaginal wet preparation in the emergency department (ED) are associated with emergency physician diagnoses of UTIs and positive urine cultures. Methods: We conducted a retrospective analysis examining a dataset of women (≥18 years of age) who received both a genital wet preparation and urine testing in the ED. Both chi-square and multivariable regression analysis were performed. Results: We analyzed 14,952 encounters. On both univariable and multivariable analyses, emergency physicians diagnosed significantly fewer clue cell-positive women with a UTI (10.9% diagnosed with UTI vs 13.1% without UTI) (P <.001). Women with clue cells on vaginal wet preparation were not more likely to have a positive urine culture or have a urine culture growing Escherichia coli. Pregnant women with clue cells on vaginal wet preparation were not more likely to have a UTI or have a positive urine culture. Conclusion: Emergency physicians diagnosed significantly fewer women with UTIs when they found clue cells on vaginal wet preparation. Clue cells on vaginal wet preparation were not associated with an increased likelihood of a positive urine culture or having E. coli growing in the urine.

Introduction: Emergency departments (ED) are rapidly replacing conventional troponin assays with high-sensitivity troponin tests. We sought to evaluate emergency physician utilization of troponin tests before and after high-sensitivity troponin introduction in our ED. Methods: We retrospectively examined 9,477 ED encounters, identifying the percentage in which physicians ordered a serum troponin both before and after our institution adopted a high-sensitivity troponin test. Results: After introduction of high-sensitivity troponin testing, the percentage of ED encountersin which physicians ordered troponin studies decreased (28.3% before vs 22% after; P <.001),with the drop most pronounced in admitted patients (decrease of 10.9% [95% confidenceinterval [CI]: 7.3%- 14.5%] in admitted patients vs decrease of 3.6% [95% CI: 1.7%- 5.4%]in discharged patients; P<.001) Conclusion: Introduction of high-sensitivity troponin testing was associated with a decrease in troponin ordering. While the reasons for this are unclear, it is possible that physicians became more selective in their ordering behavior because of the lower specificity of high-sensitivity troponin.