Practice Variation and Effects of E-Mail Only Performance Feedback on Resource Use in the Emergency Department

Abstract

Objectives

Higher resource utilization in the management of pediatric patients with undifferentiated vomiting and/or diarrhea does not correlate consistently with improved outcomes or quality of care. Performance feedback has been shown to change physician practice behavior and may be a mechanism to minimize practice variation. We aimed to evaluate the effects of electronic mail (e-mail) only, provider-level performance feedback on the ordering and admission practice variation of pediatric emergency physicians for patients presenting with undifferentiated vomiting and/or diarrhea. Design: We conducted a prospective, quality improvement intervention and collected data over 3 consecutive fiscal years (FY). Setting: Single, tertiary-care pediatric emergency department. Participants: We collected admission and ordering practices data on 19 physicians during baseline, intervention and post-intervention periods. Intervention: We provided physicians with quarterly email-based performance reports during the intervention phase. Main Outcomes Measured: We measured admission rate and created four categories for ordering practices: no orders, laboratory orders, pharmacy orders and radiology orders.

Results

There was wide (2-3 fold) practice variation among physicians. Admission rates ranged from 15-30%, laboratory orders from 19-43%, pharmacy orders from 29-57%, and radiology orders from 11-30%. There was no statistically significant difference in the proportion of patients admitted or with radiology or pharmacy orders placed between pre-intervention, intervention or post-intervention periods (p = 0.58, p = 0.19, and p = 0.75, respectively). There was a significant but very small decrease in laboratory orders between the pre-intervention and post-intervention periods.

Conclusions

Performance feedback provided only via e-mail to pediatric emergency physicians on a quarterly basis does not seem to significantly impact management practices for patients with undifferentiated vomiting and/or diarrhea.

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