Department of Emergency Medicine, Inselspital Berne, Bern, Switzerland.
Center for Educational Measurement, University of Oslo, Oslo, Norway.
Emerg Med J. 2020 Sep;37(9):546-551. doi: 10.1136/emermed-2019-209022. Epub 2020 Jul 9.
A major cause for concern about increasing ED visits is that ED care is expensive. Recent research suggests that ED resource consumption is affected by patients' health status, varies between physicians and is context dependent. The aim of this study is to determine the relative proportion of characteristics of the patient, the physician and the context that contribute to ED resource consumption.
Data on patients, physicians and the context were obtained in a prospective observational cohort study of patients hospitalised to an internal medicine ward through the ED of the University Hospital Bern, Switzerland, between August and December 2015. Diagnostic resource consumption in the ED was modelled through a multilevel mixed effects linear regression.
In total, 473 eligible patients seen by one of 38 physicians were included in the study. Diagnostic resource consumption heavily depends on physicians' ratings of case difficulty (p<0.001, z-standardised regression coefficient: 147.5, 95% CI 87.3 to 207.7) and-less surprising-on patients' acuity (p<0.001, 126.0, 95% CI 65.5 to 186.6). Neither the physician per se, nor their experience, the patients' chronic health status or the context seems to have a measurable impact (all p>0.05).
Diagnostic resource consumption in the ED is heavily affected by physicians' situational confidence. Whether we should aim at altering physician confidence ultimately depends on its calibration with accuracy.
越来越多的人担心急诊科就诊量增加，主要是因为急诊科的医疗费用昂贵。最近的研究表明，急诊科资源的消耗受到患者健康状况、医生之间的差异以及具体情况的影响。本研究旨在确定患者、医生和环境的特征中，哪些因素对急诊科资源的消耗有相对影响。
本研究为前瞻性观察队列研究，于 2015 年 8 月至 12 月在瑞士伯尔尼大学医院的急诊科将内科病房收治的患者纳入研究，收集了患者、医生和环境的数据。通过多水平混合效应线性回归模型对急诊科的诊断资源消耗进行建模。
共纳入 38 名医生诊治的 473 名符合条件的患者。诊断资源的消耗严重依赖于医生对病例难度的评分（p<0.001，标准化回归系数：147.5，95%可信区间 87.3 至 207.7），而且并不令人惊讶的是，还严重依赖于患者的病情严重程度（p<0.001，126.0，95%可信区间 65.5 至 186.6）。医生本身、其经验、患者的慢性健康状况或环境似乎都没有可衡量的影响（均 p>0.05）。
急诊科的诊断资源消耗严重受到医生的情境信心的影响。我们是否应该试图改变医生的信心，最终取决于其与准确性的校准。
