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

Abstract

Hospitalized patients access specialized expertise and procedures through the ritualized process of subspecialty consultation. 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. 1 Elsewhere in JAMA Network Open, Kern-Goldberger and colleagues 2 begin to examine who gets pediatric specialty consultation and why.Among hospitalized adults, we already know that there are a wide range of hospital, physician, and patient factors associated with how a specialist gets involved in a patient's care. First and foremost, patients who have more severe illness require more care, which often translates to more consultations. But patient acuity alone does not explain all of the variation in consultation seen in adult patients. 3,4 For example, hospitals may have more or fewer resources, different specialist availability on weekends, or variable approaches to specialist staffing. Some specialists may work largely on fee for service, leading to more care. Alternatively, rates of consultation may be lower when fellows in training are responsible for the work. Finally, the primary clinician herself may have certain baseline tendencies to use consultation, which may be about medical knowledge or clinical confidence or simply personal preference.Kern-Goldberger and colleagues 2 have investigated consultation for another population of hospitalized patients: children. In their article, 2 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.What the authors uncovered was a series of hypothesis-generating findings. First and foremost, there was an enormous amount of variation between physicians in how they engaged consultants: physicians in the topmost quartile had twice the rate of consultation as physicians in the lowest quartile. Put another way, if we assume families do not choose their pediatric hospitalist, pediatric patients admitted to top-consulting hospitalists are getting randomized to twice the strength of an intervention as those patients randomized to the lowest quartile of consultant users.What this means is we can add pediatric specialist consultation to the list of highly variable behaviors in health care. Admittedly, we still do not know what the right amount of consultation is, either for hospitalized adults or for hospitalized children. Is twice the consultation dose safe? Or just right? Some large amount of consultation is because patients need specialized care. However, it seems reasonable to hypothesize that at least some proportion of consultation is simply more care rather than necessary care. For ex...