Administration of Emergency Medicine| Volume 54, ISSUE 5, P702-710.e1, May 2018

Interphysician Differences in Emergency Department Length of Stay

Published:February 14, 2018DOI:



      Emergency physicians differ in many ways with respect to practice. One area in which interphysician practice differences are not well characterized is emergency department (ED) length of stay (LOS).


      To describe how ED LOS differs among physicians.


      We performed a 3-year, five-ED retrospective study of non-fast-track visits evaluated primarily by physicians. We report each provider's observed LOS, as well as each provider's ratio of observed LOS/expected LOS (LOSO/E); we determined expected LOS based on site average adjusted for the patient characteristics of age, gender, acuity, and disposition status, as well as the time characteristics of shift, day of week, season, and calendar year.


      Three hundred twenty-seven thousand, seven hundred fifty-three visits seen by 92 physicians were eligible for analysis. For the five sites, the average shortest observed LOS was 151 min (range 106–184 min), and the average longest observed LOS was 232 min (range 196–270 min); the average difference was 81 min (range 69–90 min). For LOSO/E, the average lowest LOSO/E was 0.801 (range 0.702–0.887), and the average highest LOSO/E was 1.210 (range 1.186–1.275); the average difference between the lowest LOSO/E and the highest LOSO/E was 0.409 (range 0.305–0.493).


      There are significant differences in ED LOS at the level of the individual physician, even after accounting for multiple confounders. We found that the LOSO/E for physicians with the lowest LOSO/E at each site averaged approximately 20% less than predicted, and that the LOSO/E for physicians with the highest LOSO/E at each site averaged approximately 20% more than predicted.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Emergency Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Marin J.R.
        • Wang L.
        • Winger D.G.
        • Mannix R.C.
        Variation in computed tomography imaging for pediatric injury-related emergency visits.
        J Pediatr. 2015; 167: 897-904.e3
        • Pines J.M.
        • Hollander J.E.
        • Isserman J.A.
        • et al.
        The association between physician risk tolerance and imaging use in abdominal pain.
        Am J Emerg Med. 2009; 27: 552-557
        • Aronson P.L.
        • Thurm C.
        • Alpern E.R.
        • et al.
        Variation in care of the febrile young infant <90 days in US pediatric emergency departments.
        Pediatrics. 2014; 134: 667-677
        • Florin T.A.
        • French B.
        • Zorc J.J.
        • Alpern E.R.
        • Shah S.S.
        Variation in emergency department diagnostic testing and disposition outcomes in pneumonia.
        Pediatrics. 2013; 132: 237-244
        • Bourgeois F.T.
        • Monuteaux M.C.
        • Stack A.M.
        • Neuman M.I.
        Variation in emergency department admission rates in US children's hospitals.
        Pediatrics. 2014; 134: 539-545
        • Abualenain J.
        • Frohna W.J.
        • Shesser R.
        • Ding R.
        • Smith M.
        • Pines J.M.
        Emergency department physician-level and hospital-level variation in admission rates.
        Ann Emerg Med. 2013; 61: 638-643
        • Bursch B.
        • Beezy J.
        • Shaw R.
        Emergency department satisfaction: what matters most?.
        Ann Emerg Med. 1993; 22: 586-591
        • Wiler J.L.
        • Gentle C.
        • Halfpenny J.M.
        • et al.
        Optimizing emergency department front-end operations.
        Ann Emerg Med. 2010; 55: 142-160.e1
        • Imperato J.
        • Morris D.S.
        • Binder D.
        • et al.
        Physician in triage improves emergency department patient throughput.
        Intern Emerg Med. 2012; 7: 457-462
        • Traub S.J.
        • Wood J.P.
        • Kelley J.
        • et al.
        Emergency department rapid medical assessment: overall effect and mechanistic considerations.
        J Emerg Med. 2015; 48: 620-627
        • Soremekun O.A.
        • Terwiesch C.
        • Pines J.M.
        Emergency medicine: an operations management view.
        Acad Emerg Med. 2011; 18: 1262-1268
        • Saghafian G.A.S.
        • Traub S.
        Operations research/managment contributions to emergency department patient flow optimization: review and research prospects.
        IIE Trans Healthc Syst Eng. 2015; 5: 101-123
        • Mercuri M.
        • Natarajan M.K.
        • Norman G.
        • Gafni A.
        An even smaller area variation: differing practice patterns among interventional cardiologists within a single high volume tertiary cardiac centre.
        Health Policy. 2012; 104: 179-185
        • Tan A.
        • Zhou J.
        • Kuo Y.F.
        • Goodwin J.S.
        Variation among primary care physicians in the use of imaging for older patients with acute low back pain.
        J Gen Intern Med. 2016; 31: 156-163
        • Gans L.N.
        • Madelbaum A.
        • Shen H.
        • Ye H.
        Service times in call centers: agent heterogeneity and learning with some operational consequences.
        in: Berger J.O. Cai T.T. Johnstone I.M. Borrowing strength: theory powering applications – A Festschrift for Lawrence D. Brown. Institute of Mathematical Statistics, Beachwood, OH2010: 99-123
        • Mullins P.M.
        • Pines J.M.
        National ED crowding and hospital quality: results from the 2013 Hospital Compare data.
        Am J Emerg Med. 2014; 32: 634-639
        • Seow V.K.
        • Lin A.C.
        • Lin I.Y.
        • et al.
        Comparing different patterns for managing febrile children in the ED between emergency and pediatric physicians: impact on patient outcome.
        Am J Emerg Med. 2007; 25: 1004-1008
        • Weiner S.G.
        • Ruffing R.P.
        • Barnewolt B.A.
        A comparison of resource utilization between emergency physicians and pediatric emergency physicians.
        Pediatr Emerg Care. 2012; 28: 869-872
        • McCarthy M.L.
        • Ding R.
        • Pines J.M.
        • et al.
        Provider variation in fast track treatment time.
        Med Care. 2012; 50: 43-49
        • Gardner R.L.
        • Sarkar U.
        • Maselli J.H.
        • Gonzales R.
        Factors associated with longer ED lengths of stay.
        Am J Emerg Med. 2007; 25: 643-650
        • Kocher K.E.
        • Meurer W.J.
        • Desmond J.S.
        • Nallamothu B.K.
        Effect of testing and treatment on emergency department length of stay using a national database.
        Acad Emerg Med. 2012; 19: 525-534
        • Forster A.J.
        • Stiell I.
        • Wells G.
        • Lee A.J.
        • van Walraven C.
        The effect of hospital occupancy on emergency department length of stay and patient disposition.
        Acad Emerg Med. 2003; 10: 127-133
        • Lucas R.
        • Farley H.
        • Twanmoh J.
        • et al.
        Emergency department patient flow: the influence of hospital census variables on emergency department length of stay.
        Acad Emerg Med. 2009; 16: 597-602
        • Wiler J.L.
        • Handel D.A.
        • Ginde A.A.
        • et al.
        Predictors of patient length of stay in 9 emergency departments.
        Am J Emerg Med. 2012; 30: 1860-1864
        • Wallbrecht J.
        • Hodes-Villamar L.
        • Weiss S.J.
        • Ernst A.A.
        No difference in emergency department length of stay for patients with limited proficiency in English.
        South Med J. 2014; 107: 1-5
        • Patterson B.W.
        • Batt R.J.
        • Wilbanks M.D.
        • Otles E.
        • Westergaard M.C.
        • Shah M.N.
        Cherry picking patients: examining the interval between patient rooming and resident self-assignment.
        Acad Emerg Med. 2016; 23: 679-684
        • Traub S.J.
        • Stewart C.F.
        • Didehban R.
        • et al.
        Emergency Department Rotational Patient Assignment.
        Ann Emerg Med. 2016; 67: 206-215
        • Abualenain J.
        • Frohna W.J.
        • Smith M.
        • et al.
        The prevalence of quality issues and adverse outcomes among 72-hour return admissions in the emergency department.
        J Emerg Med. 2013; 45: 281-288
        • Pham J.C.
        • Kirsch T.D.
        • Hill P.M.
        • DeRuggerio K.
        • Hoffmann B.
        Seventy-two-hour returns may not be a good indicator of safety in the emergency department: a national study.
        Acad Emerg Med. 2011; 18: 390-397
        • Klasco R.S.
        • Wolfe R.E.
        • Wong M.
        Assessing the rates of error and adverse events in the ED.
        Am J Emerg Med. 2015; 33: 1786-1789
        • Krall S.P.
        • Cornelius A.P.
        • Addison J.B.
        Hospital factors impact variation in emergency department length of stay more than physician factors.
        West J Emerg Med. 2014; 15: 158-164