Factors Associated With Inpatient Subspecialty Consultation Patterns Among Pediatric Hospitalists

Abstract

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 < .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.

Specialty Consultation Use by Pediatric Hospitalists—A New Type of Health Care Variation

“…In adult medicine, the commonplace process of calling a consult and engaging a specialist in a patient’s care has a broad range of drivers and multiple opportunities for failure . Elsewhere in JAMA Network Open, Kern-Goldberger and colleagues begin to examine who gets pediatric specialty consultation and why.…”

“…Kern-Goldberger and colleagues have investigated consultation for another population of hospitalized patients: children. In their article, the authors conducted a retrospective cohort study of 92 physicians caring for 7283 unique patients over 15 922 patient-days and asked what factors were associated with higher rates of consultation by the primary clinicians.…”

“…Kern-Goldberger and colleagues have investigated consultation for another population of hospitalized patients: children. In their article, the authors conducted a retrospective cohort study of 92 physicians caring for 7283 unique patients over 15 922 patient-days and asked what factors were associated with higher rates of consultation by the primary clinicians. Specifically, the authors hypothesized that physician comfort with uncertainty would be a major factor in seeking greater certainty through additional expertise, a hypothesis that did not appear to be the case in their data.…”

“…If we do not easily know how much consultative care is too much, we also do not know how much is too little. The findings of Kern-Goldberger and colleagues about some of the patient factors associated with consultation ring alarm bells about areas of potential inequitable care. The authors found that White patients had more access to specialists as did patients with private insurance.…”