Does What Happens in the ED Stay in the ED? The Effects of Emergency Department Physician Workload on Post-ED Care Use

Abstract

Problem Definition: Emergency department (ED) crowding has been a persistent concern in healthcare systems in the U.S. and other developed countries. As such, many researchers have studied its effects on outcomes within the ED. We study the effects of ED crowding on system performance outside the ED, specifically post-ED care utilization. Further, we explore the mediating effects of care intensity in the ED on post-ED care use.
Methodology/Results: We utilize a dataset assembled from more than four years of microdata from a large U.S. hospital and exhaustive billing data in an integrated health system. We use count models and instrumental variable analyses to answer the proposed research questions.We show that there is an increasing concave relationship between ED physician workload and post-ED care use. When ED workload increases from its 5th percentile to the median, the number of post-discharge care events (i.e., medical services) for patients who are discharged home from the ED increases by 5% and it is stable afterwards. Further, we identify physician test ordering behavior as a mechanism for this effect: when the physician is busier, she responds by ordering more tests for less severe patients. We document that this “extra” testing generates “extra” post-ED care utilization for these patients.
Managerial Implications: This paper contributes new insights on how physician and patient behavior under ED crowding impacts a previously unstudied system performance measure: post-ED care utilization. Our findings suggest that prior studies estimating the cost of ED crowding underestimate the true effect, as they do not consider the “extra” post-ED care utilization.

Keywords: healthcare, service operations, behavioral operations, queuing, emergency department, multitasking, utilization, empirical