Impact of Emergency Clinician Admit Tendencies for Chest Pain on Downstream Care and Outcomes

Chest pain leads to over 7 million emergency department (ED) visits annually, but

Using 2007–2021 data from a national commercial and Medicare Advantage insurer, we analyzed 223,645 ED visits with a principal diagnosis of chest pain managed by 19,003 clinicians across 2,273 EDs. We excluded visits that had other significant cardiac diagnoses or occurred after recent coronary testing or AMI treatments. To leverage the quasi-randomization of patients to clinicians, within each ED, we classified clinicians as high- vs low-admitting by comparing their adjusted hospitalization rates (inpatient and observation). Study outcomes included downstream cardiac/stress testing, coronary procedures, subsequent AMI admissions, and costs. Using generalized estimating equations, we modeled outcomes as predicted by high vs low-admitting clinicians, adjusting for patient characteristics, temporal controls, and hospital fixed effects.

Patient characteristics were similar between high- and low-admitting clinicians (Mean age: 48.4; 53.9% female). High-admitting clinician visits had more downstream care, including 7-day cardiac testing (adjusted rate ratio [aRR] 1.21 [95% CI 1.16–1.26]) and 30-day coronary interventions (aRR 1.14 [95% CI 1.11–1.18]). Subsequent AMI admissions showed no differences at 30 days (aRR 0.98 [95% CI 0.83–1.14]) or 180 days (aRR 0.96 [95% CI 0.83–1.08]). High-admitting clinicians were associated with 11.3% higher total costs and 8.5% more patients incurring out-of-pocket costs of ≥$1,000 at 30 days.

Higher clinician hospitalization rates for chest pain were linked to increased testing, interventions, and costs, but did not lower AMI risks. Future interventions that reduce marginal hospitalizations among high-admitting clinicians may prevent unnecessary care cascades and reduce cost burdens. Limitations include the lack of clinical granularity and mortality in claims data.