Pediatric Emergency Care Variation: Might Normothetic Data Undermine Adaptive Expertise?

Purpose: Practice variation across physicians is commonly attributed to idiosyncratic tendencies. What factors contribute to physicians' practice variation in the disposition of children with asthma exacerbation? How do metrics demonstrating variation impact physicians and learners? Methods: In this social constructivist qualitative study, we interviewed 11 Pediatric Emergency Medicine attendings, purposively sampling across a spectrum of acute asthma exacerbation admission rates. Participants 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 demonstrating disposition rates across the physician group and reflected on the 1) quality of the metric and 2) impact on practice. We used reflexive thematic analysis to describe patterns across the data that addressed the study's research questions. Results: Participants cited factors at the patient, caregiver, clinical care team, clinical environment, and personal practice levels that might result in variation. Participants framed the ability to weigh these sometimes competing factors as a reflection of patient-centered care. But when presented with a group-level data display, participants were surprised by the variation, valued seeing how they practiced compared to peers, and sometimes expressed a willingness to alter their practices to be "nearer the mean." Conclusions: Some variation in care may be driven by physician adaptive expertise, which is not fully captured through metric-driven nomothetic data. Though metrics are fundamental to understanding practice patterns, decontextualized aggregations of data may risk minimizing, or even framing as deviant, the expertise exercised by physicians when they weigh multiple factors in decision-making.