Payment Innovation in Emergency Care: A Case for Global Clinician Budgets.

The fee-for-service funding model for US emergency department (ED) clinician groups is increasingly fragile. Traditional fee-for-service payment systems offer no financial incentives to improve quality, address population health, or make value-based clinical decisions. Fee-for-service also does not support maintaining ED capacity to handle peak demand periods. In fee-for-service, clinicians rely heavily on cross-subsidization, where high reimbursement from commercial payors offsets low reimbursement from government payors and the uninsured. Although fee-for-service survived decades of steady cuts in government reimbursement rates, it is increasingly strained because of visit volatility and the effects of the No Surprises Act, which is driving down commercial reimbursement. Financial pressures on ED clinician groups and higher hospital boarding and clinical workloads are increasing workforce attrition. Here, we propose an alternative model to address some of these fundamental issues: an all-payer-funded, voluntary global budget for ED clinician services. If designed and implemented effectively, the model could support robust clinician staffing over the long term, ensure stability in clinical workload, and potentially improve equity in payments. The model could also be combined with population health programs (eg, pre-ED and post-ED telehealth, frequent ED use programs, and other innovations), offering significant payer returns and addressing quality and value. A linked program could also change hospital incentives that contribute to boarding. Strategies exist to test and refine ED clinician global budgets through existing government programs in Maryland and potentially through state-level legislation as a precursor to broader adoption.

Emergency Medicine Postgraduate Year, Laryngoscopic View, and Endotracheal Tube Placement Success.

STUDY OBJECTIVE: Prior work has found first-attempt success improves with emergency medicine (EM) postgraduate year (PGY). However, the association between PGY and laryngoscopic view - a key step in successful intubation - is unknown. We examined the relationship among PGY, laryngoscopic view (ie, Cormack-Lehane view), and first-attempt success. METHODS: We performed a retrospective analysis of the National Emergency Airway Registry, including adult intubations by EM PGY 1 to 4 resident physicians. We used inverse probability weighting with propensity scores to balance confounders. We used weighted regression and model comparison to estimate adjusted odds ratios (aOR) with 95% confidence intervals (CIs) between PGY and Cormack-Lehane view, tested the interaction between PGY and Cormack-Lehane view on first-attempt success, and examined the effect modification of Cormack-Lehane view on the association between PGY and first-attempt success. RESULTS: After exclusions, we included 15,453 first attempts. Compared to PGY 1, the aORs for a higher Cormack-Lehane grade did not differ from PGY 2 (1.01; 95% CI 0.49 to 2.07), PGY 3 (0.92; 0.31 to 2.73), or PGY 4 (0.80; 0.31 to 2.04) groups. The interaction between PGY and Cormack-Lehane view was significant (P-interaction<0.001). In patients with Cormack-Lehane grade 3 or 4, the aORs for first-attempt success were higher for PGY 2 (1.80; 95% CI 1.17 to 2.77), PGY 3 (2.96; 1.66 to 5.27) and PGY 4 (3.10; 1.60 to 6.00) groups relative to PGY 1. CONCLUSION: Compared with PGY 1, PGY 2, 3, and 4 resident physicians obtained similar Cormack-Lehane views but had higher first-attempt success when obtaining a grade 3 or 4 view.

First-Attempt Success Between Anatomically and Physiologically Difficult Airways in the National Emergency Airway Registry.

BACKGROUND: In the emergency department (ED), certain anatomical and physiological airway characteristics may predispose patients to tracheal intubation complications and poor outcomes. We hypothesized that both anatomically difficult airways (ADAs) and physiologically difficult airways (PDAs) would have lower first-attempt success than airways with neither in a cohort of ED intubations. METHODS: We performed a retrospective, observational study using the National Emergency Airway Registry (NEAR) to examine the association between anticipated difficult airways (ADA, PDA, and combined ADA and PDA) vs those without difficult airway findings (neither ADA nor PDA) with first-attempt success. We included adult (age ≥14 years) ED intubations performed with sedation and paralysis from January 1, 2016 to December 31, 2018 using either direct or video laryngoscopy. We excluded patients in cardiac arrest. The primary outcome was first-attempt success, while secondary outcomes included first-attempt success without adverse events, peri-intubation cardiac arrest, and the total number of airway attempts. Mixed-effects models were used to obtain adjusted estimates and confidence intervals (CIs) for each outcome. Fixed effects included the presence of a difficult airway type (independent variable) and covariates including laryngoscopy device type, intubator postgraduate year, trauma indication, and patient age as well as the site as a random effect. Multiplicative interaction between ADAs and PDAs was assessed using the likelihood ratio (LR) test. RESULTS: Of the 19,071 subjects intubated during the study period, 13,938 were included in the study. Compared to those without difficult airway findings (neither ADA nor PDA), the adjusted odds ratios (aORs) for first-attempt success were 0.53 (95% CI, 0.40-0.68) for ADAs alone, 0.96 (0.68-1.36) for PDAs alone, and 0.44 (0.34-0.56) for both. The aORs for first-attempt success without adverse events were 0.72 (95% CI, 0.59-0.89) for ADAs alone, 0.79 (0.62-1.01) for PDAs alone, and 0.44 (0.37-0.54) for both. There was no evidence that the interaction between ADAs and PDAs for first-attempt success with or without adverse events was different from additive (ie, not synergistic/multiplicative or antagonistic). CONCLUSIONS: Compared to no difficult airway characteristics, ADAs were inversely associated with first-attempt success, while PDAs were not. Both ADAs and PDAs, as well as their interaction, were inversely associated with first-attempt success without adverse events.

Emergency Department Volume, Severity, and Crowding Since the Onset of the Coronavirus Disease 2019 Pandemic.

STUDY OBJECTIVE: We describe emergency department (ED) visit volume, illness severity, and crowding metrics from the onset of the coronavirus disease 2019 (COVID-19) pandemic through mid-2022. METHODS: We tabulated monthly data from 14 million ED visits on ED volumes and measures of illness severity and crowding from March 2020 through August 2022 compared with the same months in 2019 in 111 EDs staffed by a national ED practice group in 18 states. RESULTS: Average monthly ED volumes fell in the early pandemic, partially recovered in 2022, but remained below 2019 levels (915 per ED in 2019 to 826.6 in 2022 for admitted patients; 3,026.9 to 2,478.5 for discharged patients). The proportion of visits assessed as critical care increased from 7.9% in 2019 to 11.0% in 2022, whereas the number of visits decreased (318,802 to 264,350). Visits billed as 99285 (the highest-acuity Evaluation and Management code for noncritical care visits) increased from 35.4% of visits in 2019 to 40.0% in 2022, whereas the number of visits decreased (1,434,454 to 952,422). Median and median of 90th percentile length of stay for admitted patients rose 32% (5.2 to 6.9 hours) and 47% (11.7 to 17.4 hours) in 2022 versus 2019. Patients leaving without treatment rose 86% (2.9% to 5.4%). For admitted psychiatric patients, the 90th percentile length of stay increased from 20 hours to more than 1 day. CONCLUSION: ED visit volumes fell early in the pandemic and have only partly recovered. Despite lower volumes, ED crowding has increased. This issue is magnified in psychiatric patients.

Incidence of rescue surgical airways after attempted orotracheal intubation in the emergency department: A National Emergency Airway Registry (NEAR) Study.

BACKGROUND: Cricothyrotomy is a critical technique for rescue of the failed airway in the emergency department (ED). Since the adoption of video laryngoscopy, the incidence of rescue surgical airways (those performed after at least one unsuccessful orotracheal or nasotracheal intubation attempt), and the circumstances where they are attempted, has not been characterized. OBJECTIVE: We report the incidence and indications for rescue surgical airways using a multicenter observational registry. METHODS: We performed a retrospective analysis of rescue surgical airways in subjects ≥14 years of age. We describe patient, clinician, airway management, and outcome variables. RESULTS: Of 19,071 subjects in NEAR, 17,720 (92.9%) were ≥14 years old with at least one initial orotracheal or nasotracheal intubation attempt, 49 received a rescue surgical airway attempt, an incidence of 2.8 cases per 1000 (0.28% [95% confidence interval 0.21 to 0.37]). The median number of airway attempts prior to rescue surgical airways was 2 (interquartile range 1, 2). Twenty-five were in trauma victims (51.0% [36.5 to 65.4]), with neck trauma being the most common traumatic indication (n = 7, 14.3% [6.4 to 27.9]). CONCLUSION: Rescue surgical airways occurred infrequently in the ED (0.28% [0.21 to 0.37]), with approximately half performed due to a trauma indication. These results may have implications for surgical airway skill acquisition, maintenance, and experience.

Four- and three-year emergency medicine residency graduates perform similarly in their first year of practice compared to experienced physicians.

INTRODUCTION: United States emergency medicine (EM) post-graduate training programs vary in training length, either 4 or 3 years. However, it is unknown if clinical care by graduates from the two curricula differs in the early post-residency period. METHODS: We performed a retrospective observational study comparing measures of clinical care and practice patterns between new graduates from 4- and 3-year EM programs with experienced new physician hires as a reference group. We included emergency department (ED) encounters from a national EM group (2016-19) between newly hired physicians from 4- and 3- year programs and experienced new hires (>2 years' experience) during their first year of practice with the group. Primary outcomes were at the physician-shift level (patients per hour and relative value units [RVUs] per hour) and encounter-level (72-h return visits with admission/transfer and discharge length of stay [LOS]). Secondary outcomes included discharge opioid prescription rates, test ordering, computer tomography (CT) use, and admission/transfer rate. We compared outcomes using multivariable linear regression models that included patient, shift, and facility-day characteristics, and a facility fixed effect. We hypothesized that experienced new hires would be most efficient, followed by new 4-year graduates and then new 3-year graduates. RESULTS: We included 1,084,085 ED encounters by 4-year graduates (n = 39), 3-year graduates (n = 70), and experienced new hires (n = 476). There were no differences in physician-level and encounter-level primary outcomes except discharge LOS was 10.60 min (2.551, 18.554) longer for 4-year graduates compared to experienced new hires. Secondary outcomes were similar among the three groups except 4- and 3-year new graduates were less likely to prescribe opioids to discharged patients, -3.70% (-5.768, -1.624) and - 3.38% (-5.136, -1.617) compared to experienced new hires. CONCLUSIONS: In this sample, measures of clinical care and practice patterns related to efficiency, safety, and flow were largely similar between the physician groups; however, experienced new hires were more likely to prescribe opioids than new graduates. These results do not support recommending a specific length of residency training in EM.

Comparison of Rigid and Articulating Video Stylets During Simulated Endotracheal Intubation With Hyperangulated Video Laryngoscopy.

BACKGROUND: Endotracheal tube delivery through the vocal cords can be challenging with hyperangulated video laryngoscopy due to the acute angle around the tongue and surrounding airway structures. Articulating video stylets may mitigate this issue by equipping an endotracheal tube stylet with an operator-controlled articulating end that has an additional camera at the tip. OBJECTIVES: We compared operator-reported ease of intubation between the traditional rigid stylet (GlideRiteⓇ Rigid Stylet, Verathon Inc., Bothell, WA) and the articulating video stylet (ProVu™ Video Stylet, Flexicare Inc., Irvine, CA) with a hyperangulated video laryngoscope (GlideScopeⓇ, Verathon Inc., Bothell, WA). METHODS: Participants performed simulated intubation using a hyperangulated video laryngoscope with both stylets in random order. We compared operator-reported ease of intubation on a 0-100 visual analogue scale (VAS), best percentage of glottic opening (POGO), and time to intubation. We compared outcomes using a paired t-test or the asymptotic Wilcoxon-Pratt signed-rank test dependent on normality. RESULTS: We enrolled a convenience sample of 16 emergency department attendings, residents, and physician assistant postgraduate trainees. The median operator-reported ease of intubation on VAS was 20 (interquartile range 9, 30) for the rigid stylet and 20 (10, 30) for the articulating video stylet (p = 0.832). However, the rigid stylet had a slightly shorter mean time to intubation compared with the articulating video stylet, 6.9 (standard deviation 2.5) vs. 10.3 (4.1) s, respectively (p = 0.017). POGO was similar between groups. CONCLUSIONS: During simulated endotracheal intubation, the rigid and articulating video stylets had similar operator-reported ease of intubation.

Prehospital Cardiac Arrest Airway Management: An NAEMSP Position Statement and Resource Document.

Airway management is a critical component of out-of-hospital cardiac arrest (OHCA) resuscitation. Multiple cardiac arrest airway management techniques are available to EMS clinicians including bag-valve-mask (BVM) ventilation, supraglottic airways (SGAs), and endotracheal intubation (ETI). Important goals include achieving optimal oxygenation and ventilation while minimizing negative effects on physiology and interference with other resuscitation interventions. NAEMSP recommends:Based on the skill of the clinician and available resources, BVM, SGA, or ETI may be considered as airway management strategies in OHCA.Airway management should not interfere with other key resuscitation interventions such as high-quality chest compressions, rapid defibrillation, and treatment of reversible causes of the cardiac arrest.EMS clinicians should take measures to avoid hyperventilation during cardiac arrest resuscitation.Where available for clinician use, capnography should be used to guide ventilation and chest compressions, confirm and monitor advanced airway placement, identify return of spontaneous circulation (ROSC), and assist in the decision to terminate resuscitation.

Impact of video laryngoscope shape on first-attempt success during non-supine emergency department intubations.

INTRODUCTION: Laryngoscope blade shape may differentially facilitate first-attempt success in patients intubated in non-supine positions in the emergency department (ED). Therefore, we analyzed first-attempt success in ramped and upright positions stratified by hyperangulated or standard geometry video laryngoscopes (VL). METHODS: We performed a secondary analysis of the National Emergency Airway Registry (NEAR) on ED intubations from January 1, 2016 to December 31, 2018. Our primary outcome was first-attempt success, and secondary outcomes included first-attempt success without adverse events and glottic view. We included all VL intubation attempts in the ramped and upright positions on medical patients >17-years-old. We calculated adjusted odds ratios (aOR) using a multivariable logistic regression mixed-effects model with site as a random effect and blade type, obesity / morbid obesity, training level (i.e., post-graduate year), operator-perceived difficult airway, and presence of an objective difficult airway finding as fixed effects. RESULTS: Our analysis included 266 attempts with hyperangulated blades and 370 attempts with standard geometry blades in the ramped cohort, and 116 attempts with hyperangulated attempts and 55 attempts with standard geometry blades in the upright cohort. In the ramped cohort, 244 (91.7%) of hyperangulated first attempts were successful, and 341 (92.2%) of standard geometry first attempts were successful (aOR 1.02 [95% confidence interval 0.56, 1.84]). In the upright cohort, 107 (92.2%) of hyperangulated first attempts were successful, and 50 (90.9%) of standard geometry first attempts were successful (aOR 1.04 [0.28, 3.86]). There was no difference across the secondary outcomes, including first-attempt success without adverse events. CONCLUSION: Hyperangulated and standard geometry VL had similar first-attempt success in ramped and upright position intubations in the ED.

Comparison of Suction Rates Between a Standard Yankauer, a Commercial Large-Bore Suction Device, and a Makeshift Large-Bore Suction Device.

BACKGROUND: Commercial large-bore suction catheters and makeshift large-bore suction catheters with an endotracheal tube (ETT) attached to a meconium aspirator have been shown to have superior suction rates compared with a standard Yankauer. OBJECTIVES: To compare suction rates between a commercial large-bore suction catheter and a makeshift endotracheal tube-meconium aspirator (ETTMA) combination. METHODS: We measured suction rates between a standard bulb-tip Yankauer catheter (Model: K86; Cardinal Health, Waukegan, IL), a commercial large-bore catheter (Part: 43200; The Big Stick®, SSCOR, Inc., Sun Valley, CA), and an 8.0-mm standard ETT connected to a meconium aspirator (NeotechTM Products, Inc., Valencia, CA; Ref: N0101 Clear) with high-, medium-, and low-viscosity fluids. Median suction rates were calculated with interquartile ranges. The relative differences with 95% confidence intervals (CI) between the Yankauer and both the large-bore catheter and the ETTMA combination were calculated using a linear mixed-effects model. RESULTS: Each device was trialed five times with each of the three different viscosity fluids for a total of 45 trials. Overall, suction rates were faster for the large-bore suction catheter compared with the Yankauer (relative difference 22 mL/s; 95% CI 17-28) and ETTMA (8 mL/s; 95% CI 5-10). The large-bore catheter had consistently faster suction rates compared with the Yankauer and ETTMA combination across all fluid viscosities. CONCLUSIONS: The commercial large-bore suction catheter had faster suction rates than the makeshift ETTMA combination when compared with the standard Yankauer.

DO seniors and IMGs have lower match probabilities than MD seniors after adjusting for specialty choice and USMLE Step 1 score.

CONTEXT: It is unknown if US residency applicants of different educational backgrounds (US allopathic [MD], Doctor of Osteopathic Medicine [DO], and international medical graduates [IMG]) but comparable academic performance have similar match success. OBJECTIVES: Our objective was to compare match probabilities between applicant types after adjusting for specialty choice and United States Medical Licensing Examination (USMLE) Step 1 scores. METHODS: We performed a secondary analysis of published data in National Resident Matching Program (NRMP) reports from 2016, 2018, 2020, and 2022 for US MD seniors, DO seniors, and IMGs (US citizens and non-US citizens). We examined the 10 specialties with the most available spots in 2022. Average marginal effects from a multiple variable logistic regression model were utilized to estimate each non-MD senior applicant type's probability of matching into their preferred specialty compared to MD seniors adjusting for specialty choice, Step 1 score, and match year. RESULTS: Each non-MD applicant type had a lower adjusted percent difference in matching to their preferred specialty than MD seniors, -7.1 % (95 % confidence interval [CI], -11.3 to -2.9) for DO seniors, -45.6 % (-50.6 to -40.5) for US IMGs, and -56.6 % (-61.5 to -51.6) for non-US IMGs. Similarly, each non-MD applicant type had a lower adjusted percent difference in matching than MD seniors across almost all Step 1 score ranges, except for DO seniors with Step 1 scores <200 (-2.0 % [-9.5 to 5.5]). CONCLUSIONS: After adjusting for specialty choice, Step 1 score, and match year, non-US MD applicants had lower probabilities of matching into their preferred specialties than their US MD colleagues.

Holistic Review of Applicants by the United States Postgraduate Training Programs Is Not Associated With the Percentage of Female Residents.

Introduction Given the underrepresentation of female physicians in most specialties and the aim of holistic review in residency applications to improve the diversity of matriculating resident physicians in the United States (US) postgraduate medical training programs, we examined the association between holistic review and female resident representation among US postgraduate training programs. Methods We conducted a cross-sectional survey of US postgraduate training programs to inquire about their use of holistic review for resident applications (independent variable). The primary outcome was the percentage of female residents in each program, which was obtained along with other program-level characteristics from the Fellowship and Residency Electronic Interactive Database Access (FREIDA) catalog in April 2023. We limited the analysis to the 10 specialties with the most training spots in 2022, including anesthesiology, emergency medicine, family medicine, internal medicine, neurology, obstetrics and gynecology, orthopedic surgery, pediatrics, psychiatry, and surgery (general). We also examined the interactions between holistic review and specialty and the percentage of female faculty using model comparison and simple slopes analyses.  Results Of the 3,364 total programs surveyed from the 10 specialties, 222 (6.6%) responded. Responders and nonresponders had similar program-level characteristics, including program type (e.g., university, community), specialty, and reported minimum board examination scores. Of the 222 responders, 179 (80.6%) reported performing holistic review. The percentage of female residents was 49.0% (interquartile range 37.5 to 66.7) in the no holistic review group and 47.8% (35.4 to 65.0) in the holistic review group (median difference 0.9%, 95% confidence interval -6.7 to 8.3). Furthermore, there was no evidence of interaction between holistic review and either the specialty or the percentage of female faculty on the outcome of the percentage of female residents. Conclusions Holistic review of residency applications in this limited sample of US postgraduate training programs was not associated with the percentage of female residents. The role of holistic review in addressing the imbalance of male and female physicians in the healthcare workforce, particularly between specialties, remains unknown.

Defining Incidental Versus Non-incidental COVID-19 Hospitalizations.

Background Rates of COVID-19 hospitalization are an important measure of the health system burden of severe COVID-19 disease and have been closely followed throughout the pandemic. The highly transmittable, but often less severe, Omicron COVID-19 variant has led to an increase in hospitalizations with incidental COVID-19 diagnoses where COVID-19 is not the primary reason for admission. There is a strong public health need for a measure that is implementable at low cost with standard electronic health record (EHR) datasets that can separate these incidental hospitalizations from non-incidental hospitalizations where COVID-19 is the primary cause or an important contributor. Two crude metrics are in common use. The first uses in-hospital administration of dexamethasone as a marker of non-incidental COVID-19 hospitalizations. The second, used by the United States (US) CDC, relies on a limited set of COVID-19-related diagnoses (i.e., respiratory failure, pneumonia). Both measures likely undercount non-incidental COVID-19 hospitalizations. We therefore developed an improved EHR-based measure that is better able to capture the full range of COVID-19 hospitalizations. Methods We conducted a retrospective study of ED visit data from a national emergency medicine group from April 2020 to August 2023. We assessed the CDC approach, the dexamethasone-based measure, and alternative approaches that rely on co-diagnoses likely to be related to COVID-19, to determine the proportion of non-incidental COVID-19 hospitalizations. Results Of the 153,325 patients diagnosed with COVID-19 at 112 general EDs in 17 US states, and admitted or transferred, our preferred measure classified 108,243 (70.6%) as non-incidental, compared to 71,066 (46.3%) using the dexamethasone measure and 77,399 (50.5%) using the CDC measure. Conclusions Identifying non-incidental COVID-19 hospitalizations using ED administration of dexamethasone or the CDC measure provides substantially lower estimates than our preferred measure.

Pilot Study Examining Bed Angles and Heights During Ramped Position Intubation in the Emergency Department.

INTRODUCTION: Ramped positioning during emergent endotracheal intubation has been associated with fewer peri-intubation complications, including a decrease in difficult intubations, esophageal intubations, pulmonary aspiration, and hypoxemia. However, the optimal bed angle and height for ramped position intubation have not been determined. Our objective was to examine the effect bed angle and height in the ramped position may have on laryngeal views during emergent intubation in the emergency department (ED). MATERIALS AND METHODS: We performed a secondary analysis of prospectively collected quality improvement data on intubations from our ED. All adult medical intubations performed with ramped positioning in the ED over a 24-month study period (September 1, 2020, through August 30, 2022) were eligible. We compared laryngeal views using the percentage of glottic opening (POGO) score between ramp angles (≥30° and <30° from horizontal) and bed heights (relative to the intubator, including xiphoid or above, umbilicus or below, and between xiphoid and umbilicus). RESULTS: Of the 251 patients intubated during the study period, 201 were intubated in the supine position and 50 in the ramped position. Data forms were completed for 25 patients intubated using ramped position in the ED during the study period. The median ramp angle was 30° (interquartile range (IQR) 25, 40) with 16 (64%) subjects intubated at ≥30° and 9 (36%) subjects at <30°. The median POGO scores for bed angles ≥30° and <30° were 95% (IQR 79, 100) and 90% (IQR 75, 100), respectively. Bed heights varied, with four (16%) intubated at the xiphoid or above height, one (4%) at the umbilicus or below, and 20 (80%) between the xiphoid and umbilicus. The median POGO scores at each position were 95% (IQR 76, 100), 0% (IQR 0, 0), and 95% (IQR 79, 100), respectively. CONCLUSION: ED clinicians use a variety of bed angles and heights when intubating in the ramped position. More robust investigations are necessary to determine the optimal bed angle and height for ramped position intubation in the ED.

Minimum United States Medical Licensing Examination and Comprehensive Osteopathic Medical Licensing Examination Scores Often Do Not Align.

Background Many residency programs do not accept the Comprehensive Osteopathic Medical Licensing Examination (COMLEX-USA) alone for osteopathic applicants. Furthermore, among those programs that do accept the COMLEX-USA, it is unknown how programs scale their minimum COMLEX-USA scores compared to their minimum United States Medical Licensing Examination (USMLE) scores. Objective Our objective was to examine the variation of relative within-program differences between minimum USMLE Step and COMLEX-USA Level scores required for consideration by United States residency programs. Methods We performed a cross-sectional analysis of the Fellowship and Residency Electronic Interactive Database Access (FREIDA) database from April 2023, including the 10 specialties with the most training spots in 2022. These specialties were internal medicine, family medicine, pediatrics, emergency medicine, psychiatry, surgery, anesthesiology, obstetrics-gynecology, orthopedic surgery, and neurology. Within-program differences were calculated by subtracting the minimum USMLE Step 1 and 2 scores from the converted minimum USMLE Step 1 and 2 scores calculated from the minimum COMLEX-USA Level 1 and 2 scores using two conversion tools. We present differences as medians with interquartile ranges (IQR). Additionally, we report the proportion of programs with greater than 10-point differences for each step (1 and 2). Results Of the 3,364 accredited programs from the examined specialties, we included 1,477 in the Step 1 analysis and 1,227 in the Step 2 analysis with complete data. The median within-program difference between the minimum Step 1 score and the predicted Step 1 score was 12.0 (IQR 2.0, 17.0) using the Barnum and colleagues' conversion tool and -1.7 (IQR -6.2, 6.3) using the Smith and colleagues' tool. The median differences for Step 2 were 2.0 (IQR -8.0, 12.0) and -6.5 (IQR -13.9, -1.5) for each tool, respectively. Using the Barnum and Smith conversion tools, 937 (63%) and 435 (29%) programs had a greater than 10-point Step 1 score difference, respectively. Similarly, for Step 2, 564 (46%) and 515 (42%) programs had a greater than 10-point difference with each conversion tool. Conclusion There is wide variation in the within-program differences between minimum USMLE and predicted minimum USMLE (from COMLEX-USA) scores. Many programs have greater than 10-point differences, which may be a source of bias in osteopathic applicant selection.