Describing Variability of Inpatient Consultation Practices: Physician, Patient, and Admission Factors
Appropriate use of consultation can improve patient outcomes, but inappropriate use may cause harm. Factors affecting the variability of inpatient consultation are poorly understood. We aimed to describe physician-, patient-, and admission-level factors influencing the variability of inpatient consultations on general medicine services. We conducted a retrospective study of patients hospitalized from 2011 to 2016 and enrolled in the University of Chicago Hospitalist Project, which included 6,153 admissions of 4,772 patients under 69 attendings. Consultation use varied widely; a 5.7-fold difference existed between the lowest (mean, 0.613) and highest (mean, 3.47) quartiles of use (P <.01). In mixed-effect Poisson regression, consultations decreased over time, with 45% fewer consultations for admissions in 2015 than in 2011 (P <.01). Patients on nonteaching hospitalist teams received 9% more consultations than did those on teaching services (P =.02). Significant variability exists in inpatient consultation use. Further understanding may help to identify groups at high-risk for underuse/overuse and aid in the development of interventions to improve high-value care.
© 2020 Society of Hospital Medicine
Inpatient consultation is an extremely common practice with the potential to improve patient outcomes significantly.1-3 However, variability in consultation practices may be risky for patients. In addition to underuse when the benefit is clear, the overuse of consultation may lead to additional testing and therapies, increased length of stay (LOS) and costs, conflicting recommendations, and opportunities for communication breakdown.
Consultation use is often at the discretion of individual providers. While this decision is frequently driven by patient needs, significant variation in consultation practices not fully explained by patient factors exists.1 Prior work has described hospital-level variation1 and that primary care physicians use more consultation than hospitalists.4 However, other factors affecting consultation remain unknown. We sought to explore physician-, patient-, and admission-level factors associated with consultation use on inpatient general medicine services.
METHODS
Study Design
We conducted a retrospective analysis of data from the University of Chicago Hospitalist Project (UCHP). UCHP is a longstanding study of the care of hospitalized patients admitted to the University of Chicago general medicine services, involving both patient data collection and physician experience surveys.5 Data were obtained for enrolled UCHP patients between 2011-2016 from the Center for Research Informatics (CRI). The University of Chicago Institutional Review Board approved this study.
Data Collection
Attendings and patients consented to UCHP participation. Data collection details are described elsewhere.5,6 Data from EpicCare (EpicSystems Corp, Wisconsin) and Centricity Billing (GE Healthcare, Illinois) were obtained via CRI for all encounters of enrolled UCHP patients during the study period (N = 218,591).
Attending Attribution
We determined attending attribution for admissions as follows: the attending author of the first history and physical (H&P) was assigned. If this was unavailable, the attending author of the first progress note (PN) was assigned. For patients admitted by hospitalists on admitting shifts to nonteaching services (ie, service without residents/students), the author of the first PN was assigned if different from H&P. Where available, attribution was corroborated with call schedules.
Sample and Variables
All encounters containing inpatient admissions to the University of Chicago from May 10, 2011 (Electronic Health Record activation date), through December 31, 2016, were considered for inclusion (N = 51,171, Appendix 1). Admissions including only documentation from ancillary services were excluded (eg, encounters for hemodialysis or physical therapy). Admissions were limited to a length of stay (LOS) ≤ 5 days, corresponding to the average US inpatient LOS of 4.6 days,7 to minimize the likelihood of attending handoffs (N = 31,592). If attending attribution was not possible via the above-described methods, the admission was eliminated (N = 3,103; 10.9% of admissions with LOS ≤ 5 days). Finally, the sample was restricted to general medicine service admissions under attendings enrolled in UCHP who completed surveys. After the application of all criteria, 6,153 admissions remained for analysis.
