Audit of the consultation process on general internal medicine services

Conley, Joslyn; Jordan, Myechia Minter; Ghali, William A.

doi:10.1136/qshc.2007.025486

Cited by 34 publications

(20 citation statements)

References 13 publications

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“…2,9,22 In particular, Chen et al identified variability in the use of medical consultants following specific surgical procedures, 22 whereas we studied inpatient consultation more generally across the full spectrum of inpatient conditions seen in the Medicare population. While our study confirms earlier findings that sicker and more complex patients receive more consultations, we also demonstrate that patient comorbidities and prior hospitalizations contribute little to explaining the use of consultation use during acute hospitalization.…”

Section: Discussionmentioning

confidence: 99%

Variation in Inpatient Consultation Among Older Adults in the United States

et al. 2015

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BACKGROUND: Differences among hospitals in the use of inpatient consultation may contribute to variation in outcomes and costs for hospitalized patients, but basic epidemiologic data on consultations nationally are lacking. OBJECTIVE: The purpose of the study was to identify physician, hospital, and geographic factors that explain variation in rates of inpatient consultation. The primary outcome measured was number of consultations conducted during the hospitalization, summarized at the hospital level as the number of consultations per 1,000 Medicare admissions, or Bconsultation density.K EY RESULTS: Consultations occurred 2.6 times per admission on average. Among non-critical access hospitals, use of consultation varied 3.6-fold across quintiles of hospitals (933 versus 3,390 consultations per 1,000 admissions, lowest versus highest quintiles, p<0.001). Sicker patients received greater intensity of consultation (rate ratio [RR] 1.18, 95 % CI 1.17-1.18 for patients admitted to ICU; and RR 1.19, 95 % CI 1.18-1.20 for patients who died). However, even after controlling for patient-level factors, hospital characteristics also predicted differences in rates of consultation. For example, hospital size (large versus small, RR 1.31, 95 % CI 1.25-1.37), rural location (rural versus urban, RR 0.78, CI 95 % 0.76-0.80), ownership status (public versus not-for-profit, RR 0.94, 95 % CI 0.91-0.97), and geographic quadrant (Northeast versus West, RR 1.17, 95 % CI 1.12-1.21) all influenced the intensity of consultation use. CONCLUSIONS: Hospitals exhibit marked variation in the number of consultations per admission in ways not fully explained by patient characteristics. Hospital Bconsultation density^may constitute an important focus for monitoring resource use for hospitals or health systems.

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Section: Discussionmentioning

confidence: 99%

Variation in Inpatient Consultation Among Older Adults in the United States

et al. 2015

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“…8e11 Lack of efficient information exchange continues to be a formidable problem with medical consultations, resulting in inefficiency and increased health care costs. 2,12,13 We addressed how preconsultation exchange may address some of these inefficiencies.…”

Section: Discussionmentioning

confidence: 99%

Electronic Preconsultation as a Method of Quality Improvement for Urological Referrals

et al. 2014

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Introduction: Preconsultation exchange is a method to promote expedited care among health care providers through communication between primary care providers and specialists before a clinic visit. We evaluated the efficacy of a preconsultation exchange in streamlining patient visits to the urology clinic with an emphasis on resource efficiency in a safety net hospital. Methods: Between April 1, 2011 and March 31, 2012 there were 1,705 electronic referrals to our urology department. A random sample of 500 referrals was selected for evaluation, of whom 487 patients met study inclusion criteria. Scheduling outcome and preconsultation exchange were evaluated for each chief complaint. Results: Patients with operative or procedural chief complaints, or potential oncologic diagnoses were most likely to be scheduled directly to the urology clinic. Of the 487 patients 36 (7.4%) were treated for benign urological conditions by primary care providers and did not need to be seen in the urology clinic. For 13.5% of patients recommended laboratory and radiological tests were obtained before the initial urology clinic visit as a result of preconsultation exchange. Conclusions: Electronic preconsultation exchange served as a method of quality improvement by promoting urology clinic efficiency. Unnecessary appointments were limited and the completeness of appropriate laboratory and imaging studies at the initial visit was increased. Health care was streamlined by increased access to urological care and by management of benign urological conditions without a formal clinic visit in appropriate cases.

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“…In a few cases, subspecialists did not believe sufficient information was provided in the referral to make an informed decision. Both quality and quantity of information provided in referrals need further study; a recent study found that more than one in four referrals did not contain a clear clinical question 25 . Future work may need to focus on developing, adopting, and integrating referral criteria specific to the services receiving referrals and testing EHR-based referral templates that reflect such criteria.…”

Section: Discussionmentioning

confidence: 99%

Follow-up Actions on Electronic Referral Communication in a Multispecialty Outpatient Setting

et al. 2010

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OBJECTIVES: Electronic health records (EHR) enable transmission and tracking of referrals between primarycare practitioners (PCPs) and subspecialists. We used an EHR to examine follow-up actions on electronic referral communication in a large multispecialty VA facility. METHODS: We retrieved outpatient referrals to five subspecialties between October 2006 and December 2007, and queried the EHR to determine their status: completed, discontinued (returned to PCP), or unresolved (no action taken by subspecialist). All unresolved referrals, and random samples of discontinued and completed referrals were reviewed to determine whether subspecialists took follow-up actions (i.e., schedule appointments anytime in the future) within 30 days of referral-receipt. For referrals without timely follow-up, we determined whether inaction was supported by any predetermined justifiable reasons or associated with certain referral characteristics. We also reviewed if PCPs took the required action on returned information. RESULTS: Of 61,931 referrals, 22,535 were discontinued (36.4%), and 474 were unresolved (0.8%). We selected 412 discontinued referrals randomly for review. Of these, 52% lacked follow-up actions within 30 days. Appropriate justifications for inaction were documented in 69.8% (150/215) of those without action and included lack of prerequisite testing by the PCP and subspecialist opinion that no intervention was required despite referral. We estimated that at 30 days, 6.3% of all referrals were associated with an unexplained lack of follow-up actions by subspecialists. Conversely, 7.4% of discontinued referrals returned to PCPs were associated with an unexplained lack of follow-up. CONCLUSIONS: Although the EHR facilitates transmission of valuable information at the PCP-subspecialist interface, unexplained communication breakdowns in the referral process persist in a subset of cases.

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Audit of the consultation process on general internal medicine services

Cited by 34 publications

References 13 publications

Variation in Inpatient Consultation Among Older Adults in the United States

Variation in Inpatient Consultation Among Older Adults in the United States

Electronic Preconsultation as a Method of Quality Improvement for Urological Referrals

Follow-up Actions on Electronic Referral Communication in a Multispecialty Outpatient Setting

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