Variation in Inpatient Consultation Among Older Adults in the United States

Abstract

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.

Describing Variability of Inpatient Consultation Practices: Physician, Patient, and Admission Factors

“…Our results strengthen prior work demonstrating that patient-level factors alone are insufficient to explain consultation variability. 1 Hospitalists on nonteaching services called more consultations, which may reflect a higher workload on these services. Busy hospitalists on nonteaching teams may lack time to delve deeply into clinical problems and require more consultations, especially for work with heavy cognitive loads such as diagnosis.…”

Communication Skills Training for Physicians Improves Patient Satisfaction

“…1 HCAHPS scores, which measure inpatient care, are tied to the discharging physician. Because the average inpatient sees at least 3.6 physicians during a hospital stay, 2 and patients are frequently unaware of different physicians' roles in their care, 3 HCAHPS may be a poor measure of experience and satisfaction with a specific physician. In contrast, the outpatient experience survey (Clinician and Group Consumer Assessment of Healthcare Providers and Systems; CGCAHPS) is provider-specific, may soon be required, and may provide more reliable data on which to base improvement efforts.…”

Using EHR to Conduct Outcome and Health Services Research

“…These authors employed data derived from the use of different types of medical services-home health services, inpatient discharges, etc.-to draw these inferences. Subsequent investigations into national variation in care have been able to capitalize on the availability of such data electronically [4].…”