Gatekeeping Under Congestion: An Empirical Study of Referral Errors in the Emergency Department

39 Pages Posted: 17 Sep 2017

See all articles by Michael Freeman

Michael Freeman

INSEAD

Susan Robinson

Cambridge University Hospitals NHS Foundation Trust

Stefan Scholtes

Judge Business School

Date Written: September 14, 2017

Abstract

Using data from over 350,000 visits to an emergency department (ED), we study the effect of congestion on the accuracy of gatekeeping decisions (hospital admission or discharge home) and the effectiveness of a second gatekeeping stage (a clinical decision unit (CDU)) in reducing errors. While ED physicians make more gatekeeping errors when congestion increases, the change in the rates of false positives (avoidable hospitalization) and false negatives (wrongful discharge) differ substantially. We find that when congestion increases, physicians prevent an increase in wrongful discharges - a more safety-critical concern - by lowering the threshold for hospital admission. This leads to a surge in avoidable hospitalizations and creates "false demand" for hospital beds at precisely the time when ED physicians should protect this constrained resource. We show that introducing a second gatekeeping stage - to which front-line gatekeepers can pass customers if they are unable to make an accurate referral decision - can mitigate this effect. When used as a second gatekeeping stage, we find evidence that the CDU reduces both avoidable admissions and wrongful discharges, by 16.5% and 13.8%, respectively. We also demonstrate that the two-stage gatekeeping system performs better than a combined system with pooled capacity.

Keywords: gatekeeping, congestion, referral error, health care, hospitals, service operations, econometrics

Suggested Citation

Freeman, Michael and Robinson, Susan and Scholtes, Stefan, Gatekeeping Under Congestion: An Empirical Study of Referral Errors in the Emergency Department (September 14, 2017). INSEAD Working Paper No. 2017/59/TOM. Available at SSRN: https://ssrn.com/abstract=3036999 or http://dx.doi.org/10.2139/ssrn.3036999

Michael Freeman (Contact Author)

INSEAD ( email )

1 Ayer Rajah Avenue
Singapore, 138676
Singapore

Susan Robinson

Cambridge University Hospitals NHS Foundation Trust ( email )

Hills Road
Cambridge, CB2 0QQ
United Kingdom

Stefan Scholtes

Judge Business School ( email )

Trumpington Street
Cambridge, CB2 1AG
United Kingdom

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