Emergency medicine provider efficiency: The learning curve, equilibration and point of diminishing returns

Abstract

Objective: This study described the spectrum of emergency department (ED) physician performance correlating annual workload, experience and facility issues. Methods: Retrospective review reported physician hours worked comparing productivity measures - patients per hour (PPH) or relative value unit (RVU) per hour, as 'best fit' trend line and facility volume subgroups by analysis of variance. Results: 912 physicians evaluated 2 407 833 patients in 61 ED. Staff productivity was 1.72±0.44 PPH (1.2±0.30-2.1±0.32 PPH) and 4.43±1.21 RVU/h (2.9±0.80-5.4±0.82 RVU/h). There was less variation with facility size 2.58±0.36 (2.41±0.22-2.72±0.37 RVU/visit) from smaller to larger (p<0.001). Maximal efficiency occurs at 5.0 RVU/h generated at 1550 annual hours (130 monthly) compared with 1800 h full-time equivalent (FTE) physicians (R2=0.084). Productivity begins at 4.0 RVU/h for casual (<250 h/year), 4.4 RVU/h for part time (<500 h), achieving equilibrium (5.0 RVU/h) for three-quarters to full time (1250-1800 h) with a decline in full-time providers (2000-2500 h/year). Efficiency was less in smaller ED less than 15 000 (1.22±0.30 PPH, 2.9560.80 RVU/h) compared with larger greater than 45 000 (2.07±0.32 PPH, 5.43±0.82 RVU/h; p<0.001). The RVU/visit generated were less varied (2.41±0.22) in smaller versus (2.64±0.38) larger facilities with a 2.8 RVU/h equilibration point (p<0.001). Conclusion: Maximal productivity is reached at 86% (1550 h) annual workload and efficiency declines at conventional FTE (≈ 1800 h). A distinct 'learning curve' was found in newer, casual providers and smaller facilities.