Impact of Preoperative Specialty Consults on Hospitalist Comanagement of Hip Fracture Patients

Patients with preoperative specialty consults were older and had more comorbidities than patients without consults. Our findings suggest that consults contribute to delays to surgery and may lead to higher LOS and higher risk of 30-day readmission after controlling for age and comorbidities in a multivariate analysis. This observation is significant considering that consults were requested more frequently on patients with a higher comorbidity burden and included patients who did not get additional preoperative testing, suggesting that a delay from waiting for a consult alone may be deleterious. This was a unique observation in our study; prior studies examining this subject have attributed delays to additional testing and not consults alone. Even though most consult requests appear to be reasonable according to our criteria, the majority of recommendations were minor (72.9%), and 62.7% of consults resulted in no change in perioperative management. Major changes in perioperative management were noted in only 4.5% of patients.

Our finding that a majority of patients in the consult group had no significant change in perioperative management raises an important area of potential improvement in the care of hip fracture patients. We believe that narrowing indications for preoperative specialty consults may result in shorter TTS and LOS for this group of frail elderly patients without sacrificing the quality of care. Since all patients in our study were comanaged by hospitalists and patients without additional consults had similar or better outcomes, we believe that hospitalist physicians are well positioned to provide standardized comanagement to this patient group without additional consultation unless absolutely necessary.

The primary limitation of our study was that this was a retrospective case analysis. The designation of minor, moderate, or major recommendation was done after the consults were already completed, and it may not be possible to predict that a consult results in no change without it being actually performed. Additionally, our classification of recommendations is somewhat arbitrary and subjective; for example, some readers might argue that a medication change counts as a moderate recommendation. We rated a medication change to be minor as we believe that an experienced hospitalist may likely make such management decisions on their own, and if this is the only recommendation from a consult, it is not additional information critical to patient care. There may also be an “unmeasured complexity” noted by the admitting physician, which was not necessarily accounted for by multivariate analysis of age and CCI but one that led to higher mortality and readmissions. However, we feel that this “unmeasured complexity” is likely inconsequential as the vast majority of consults did not result in any change in management. We did adjust for covariates as noted, but some confounding by indication is likely to remain. Additionally, categorization of consult recommendations and consequent changes by one physician could be considered subjective. We did control for this by having another physician review the entire dataset and rate it independently for interrater reliability with excellent correlation and kappa, although these may be inflated to some degree because our chart review did not account for variability among chart extractors.

A prospective evaluation of a clinical protocol that delineates reasonable indications for a preoperative consult would be helpful to validate our findings. In our study, we noted moderate or major recommendations from a cardiologist only in cases where an active cardiac condition was suspected by the hospitalist requesting the consult; hence, limiting preoperative cardiology consults to active cardiac conditions may be a reasonable approach to evaluate in a prospective study.

In conclusion, a majority of preoperative specialty consults do not appear to meaningfully influence management and may indirectly increase morbidity by delaying surgery and extending hospital stays. Our data suggest that unless the patient is clinically unstable and likely to require active management by a consultant prior to hip fracture repair, consults may offer limited benefit. Appropriately standardized perioperative management of this patient group by hospitalist physicians appears to manage most hip fracture patients as effectively with faster TTS and shorter hospital LOS.