Association of Medicare Spending With Subspecialty Consultation for Elderly Hospitalized Adults

Yuan, Yihao; Werner, Rachel M.

doi:10.1001/jamanetworkopen.2019.1634

Cited by 7 publications

(10 citation statements)

References 25 publications

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“…Finally, subspecialty consults, although often ordered in pursuit of a better understanding of risk, almost invariably lead to further testing and increased cost. 16,17 Clearer communication from providers regarding expectations and a stepwise tiered approach from a consultant may lead to more high-value consultant recommendations.…”

Section: Management Of Incidental Findings and The Cascade Effectmentioning

confidence: 99%

An Explosive Workup for Diarrhea: The Cascade Effect From an Incidental Finding on a Laboratory Panel

Nathaniel¹,

Tchou²

2020

Hospital Pediatrics

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A 19-month-old boy with a medical history of 1 febrile seizure presented to the emergency department (ED) with 2 days of vomiting and 1 day of diarrhea. He was accompanied by his non-English-speaking mother, who reported several episodes of nonbloody, nonbilious emesis and dark brown, watery stools. The patient had decreased intake of solid foods, but he had been breastfeeding well. Because of his diarrhea, the patient' s mother was unsure how many voids he had had in the past day. He had not had fevers. The family history was significant for the patient' s father recently being diagnosed with hepatitis C. The patient' s mother brought him into the ED because of his symptoms and concern that he looked "yellow."

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Section: Management Of Incidental Findings and The Cascade Effectmentioning

confidence: 99%

An Explosive Workup for Diarrhea: The Cascade Effect From an Incidental Finding on a Laboratory Panel

Nathaniel¹,

Tchou²

2020

Hospital Pediatrics

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“…9 Studies of adult patients suggest significant subjectivity and variability in the extent of consultation utilization within and across hospitals. 2,5 While consultation practice patterns in adult populations have been characterized, 2,5,[9][10][11] our understanding of how and why pediatric hospitalists utilize consultations is limited. One descriptive study 12 found highly variable consultation utilization in 200 hospitalized children with uncertain diagnoses.…”

Section: Introductionmentioning

confidence: 99%

Factors Associated With Inpatient Subspecialty Consultation Patterns Among Pediatric Hospitalists

et al. 2023

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ImportanceSubspecialty consultation is a frequent, consequential practice in the pediatric inpatient setting. Little is known about factors affecting consultation practices.ObjectivesTo identify patient, physician, admission, and systems characteristics that are independently associated with subspecialty consultation among pediatric hospitalists at the patient-day level and to describe variation in consultation utilization among pediatric hospitalist physicians.Design, Setting, and ParticipantsThis retrospective cohort study of hospitalized children used electronic health record data from October 1, 2015, through December 31, 2020, combined with a cross-sectional physician survey completed between March 3 and April 11, 2021. The study was conducted at a freestanding quaternary children’s hospital. Physician survey participants were active pediatric hospitalists. The patient cohort included children hospitalized with 1 of 15 common conditions, excluding patients with complex chronic conditions, intensive care unit stay, or 30-day readmission for the same condition. Data were analyzed from June 2021 to January 2023.ExposuresPatient (sex, age, race and ethnicity), admission (condition, insurance, year), physician (experience, anxiety due to uncertainty, gender), and systems (hospitalization day, day of week, inpatient team, and prior consultation) characteristics.Main Outcomes and MeasuresThe primary outcome was receipt of inpatient consultation on each patient-day. Risk-adjusted consultation rates, expressed as number of patient-days consulting per 100, were compared between physicians.ResultsWe evaluated 15 922 patient-days attributed to 92 surveyed physicians (68 [74%] women; 74 [80%] with ≥3 years’ attending experience) caring for 7283 unique patients (3955 [54%] male patients; 3450 [47%] non-Hispanic Black and 2174 [30%] non-Hispanic White patients; median [IQR] age, 2.5 ([0.9-6.5] years). Odds of consultation were higher among patients with private insurance compared with those with Medicaid (adjusted odds ratio [aOR], 1.19 [95% CI, 1.01-1.42]; P = .04) and physicians with 0 to 2 years of experience vs those with 3 to 10 years of experience (aOR, 1.42 [95% CI, 1.08-1.88]; P = .01). Hospitalist anxiety due to uncertainty was not associated with consultation. Among patient-days with at least 1 consultation, non-Hispanic White race and ethnicity was associated with higher odds of multiple consultations vs non-Hispanic Black race and ethnicity (aOR, 2.23 [95% CI, 1.20-4.13]; P = .01). Risk-adjusted physician consultation rates were 2.1 times higher in the top quartile of consultation use (mean [SD], 9.8 [2.0] patient-days consulting per 100) compared with the bottom quartile (mean [SD], 4.7 [0.8] patient-days consulting per 100; P &lt; .001).Conclusions and RelevanceIn this cohort study, consultation use varied widely and was associated with patient, physician, and systems factors. These findings offer specific targets for improving value and equity in pediatric inpatient consultation.

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Section: Introductionmentioning

confidence: 99%

“…1 A separate study of 736 000 admissions of Medicare patients found subspecialty consultative care accounted for $1.3 billion of Medicare spending in 2014. 2 Given the ubiquity and expense of inpatient consultations, research has focused heavily on assessing variation in consultation use 1,[3][4][5] and association with patient-level outcomes. [6][7][8][9][10] A third research area centers on assessing communication among consultation stakeholders [11][12][13][14][15][16][17] and identifying factors that influence consultation "effectiveness."…”

Section: Introductionmentioning

confidence: 99%

Patient and Clinician Perceptions of Factors Relevant to Ideal Specialty Consultations

et al. 2022

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Key Points Question How do stakeholders envision the ideal inpatient consultation and in what ways do consultations commonly fall short of this ideal? Findings In this qualitative study of 17 specialists, 13 hospitalists, 4 patients, and 4 family members, participants identified 11 key information exchanges that occur during an ideal consultation, as well as 6 common defects and 5 contextual factors that influence how these information exchanges transpire. Meaning These findings suggest that successful inpatient consultation requires a complicated, sequenced series of time-sensitive information exchanges guided primarily by unwritten norms and highly vulnerable to failure.

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Association of Medicare Spending With Subspecialty Consultation for Elderly Hospitalized Adults

Cited by 7 publications

References 25 publications

An Explosive Workup for Diarrhea: The Cascade Effect From an Incidental Finding on a Laboratory Panel

An Explosive Workup for Diarrhea: The Cascade Effect From an Incidental Finding on a Laboratory Panel

Factors Associated With Inpatient Subspecialty Consultation Patterns Among Pediatric Hospitalists

Patient and Clinician Perceptions of Factors Relevant to Ideal Specialty Consultations

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