Comparison of resident and mid-level provider productivity in a high-acuity emergency department setting

Mid-level providers (MLPs) are used in many emergency departments (EDs) to provide care in a low-acuity, high-volume setting, and are able to see more patients and generate more relative value units (RVUs) than residents in this setting. It is unknown if MLPs are as productive as emergency medicine residents in a high-acuity setting.

To determine if there are productivity differences between residents and MLPs, as defined by patients seen (pt/h) and RVUs generated per hour (RVU/h), in a high-acuity area of the ED.

This is a retrospective review of emergency medicine residents and MLPs assigned to a high-acuity area of a single 45,000 volume community ED. Number of patients seen and RVUs generated were recorded, and pt/h, RVU/h and RVU/pt were calculated. Two-tailed t test was used to compare resident and MLP performance.

55 MLP and 98 emergency medicine residency shifts were included for comparison. During the study period, MLPs saw 1.56 pt/h (CI ± 0.14), while residents saw 1.23 pt/h (CI ± 0.06, p<0.0001). MLPs generated 3.19 RVU/h (CI ± 0.29), while residents generated 3.33 RVU/h (CI ± 0.17, p=0.43). Residents generated 2.73 RVU/pt (CI ± 0.09), while MLPs generated 2.05 RVU/pt (CI ± 0.09, p<0.0001). In comparing the subgroup of postgraduate year 3 residents (PGY3s) with MLPs, MLPs still saw significantly more patients (1.30 vs 1.56, p=0.003), but PGY3s generated 3.58 RVU/h compared with 3.19 RVU/h for MLPs (p=0.06). PGY3s generated 2.79 RVU/pt compared with 2.05 for MLPs (p<0.0001).

In a high-acuity area of the ED, MLPs see more patients per hour than residents, but generate fewer RVUs per patient. This suggests that residents may document more thoroughly than MLPs. Alternatively, MLPs may elect to see less sick patients even when working in a high-acuity area.