Gatekeeping Under Congestion: An Empirical Study of Referral Errors in the Emergency Department
39 Pages Posted: 17 Sep 2017
Date Written: September 14, 2017
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
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