546 - What Does "the Mean" Mean?: Physician Reflections on Variation in Asthma Disposition in the Pediatric Emergency Department

Publication Number: 2531.546

Laura Sartori, Childrens Hospital of Philadelphia, Philadelphia, PA, United States; Bjorn Watsjold, University of Washington School of Medicine, Seattle, WA, United States; Jonathan Ilgen, University of Washington School of Medicine, Seattle, WA, United States; Joseph J. Zorc, Childrens Hospital of Philadelphia, Wynnewood, PA, United States; Lara Varpio, Childrens Hospital of Philadelphia, Philadelphia, PA, United States; Katherine Wu, Children's Hospital of Philadelphia, Philadelphia, PA, United States; Lanelle Quzack, Childrens Hospital of Philadelphia, Folcroft, PA, United States

Background: Acute asthma exacerbation is commonly encountered in the Pediatric Emergency Department (ED), but acuity-adjusted asthma disposition rates vary by provider at our institution. This variation represents an opportunity to study how providers assess risk, make decisions, and integrate feedback on their care, with important implications for medical education.

Objective: To assess how Pediatric Emergency Medicine (PEM) attendings make disposition decisions for patients with asthma.

Design/Methods: In this exploratory qualitative study, we interviewed 11 PEM attendings, purposively sampling across a spectrum of acute asthma exacerbation disposition rates. Providers reflected on their recent care of patients with asthma, how they assess patients, and how they determine disposition. They were shown a de-identified funnel plot (Figure 1) demonstrating disposition rates across the provider group and asked them to reflect on 1) quality of the metric and 2) impact on practice.

Results: Providers cited several different system and patient factors that challenged their decision making: patient-specific factors (ex. clinical presentation), family factors (ex. confidence in home management), clinical care team factors (ex. experience of residents), the clinical environment (ex. patient volume), and individual physician factors (ex. confidence in plans) (Table 1). Through shared decision making with families and reliance on colleagues, they developed strategies for navigating uncertainty. Many saw their ability to navigate this as a valuable aspect of patient-centered care. Despite their rich discussion of diverse factors impacting care, when presented with the funnel plot, providers were surprised by the variation in disposition rate within the provider group. Providers valued the ability to see how they practiced compared to peers, with some influenced by the plot enough to express a desire to be "near the mean" and alter practice. Others questioned the metric's utility in meaningfully changing their practice (Table 2).

Conclusion(s): Multiple factors impact asthma disposition rates, resulting in variation and no clear "correct" rate. In the absence of a clear goal, providers may default to an expectation to practice "near the mean," despite appreciation for the complexity of decision making and their own expertise. Though metrics are fundamental to understanding practice patterns, decontextualized aggregations of provider data may risk minimizing, or even framing as deviant, the expertise exercised by physicians when they weigh multiple factors in decision making.

Figure 1: Acuity-Adjusted Emergency Department Inpatient Admission Rate By Attending Physician in Children Presenting with Acute Asthma Exacerbation
Each blue circle represents a Pediatric Emergency Medicine (PEM) Attending Physician, with acuity-adjusted successful discharge rate on the y-axis and number of yearly asthma encounters on the x-axis. The dashed black line represents mean rate among all PEM physicians, with the green dashed line representing 95% control limits and the red dashed line representing 99.8% control limits. Providers from across the spectrum of discharge rates were selected and interviewed within 1-2 days from last shift in a "respiratory cohort" team in the Emergency Department.

Table 1: Clinical Factors Informing Clinical Decision Making


Table 2: Clinician Reflections on Funnel Plot Data