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Original Investigation |

Use of Medical Consultants for Hospitalized Surgical Patients:  An Observational Cohort Study

Lena M. Chen, MD, MS1,2,3,4; Adam S. Wilk, BA5,6; Jyothi R. Thumma, MPH3; John D. Birkmeyer, MD3,4,7; Mousumi Banerjee, PhD3,4,8
[+] Author Affiliations
1Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
2VA Ann Arbor Healthcare System, Ann Arbor, Michigan
3Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor
4Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
5Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor
6VA Center for Clinical Management Research, Ann Arbor, Michigan
7Department of Surgery, University of Michigan, Ann Arbor
8Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor
JAMA Intern Med. 2014;174(9):1470-1477. doi:10.1001/jamainternmed.2014.3376.
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Importance  Payments around episodes of inpatient surgery vary widely among hospitals. As payers move toward bundled payments, understanding sources of variation, including use of medical consultants, is important.

Objective  To describe the use of medical consultations for hospitalized surgical patients, factors associated with use, and practice variation across hospitals.

Design, Setting, and Participants  Observational retrospective cohort study of fee-for-service Medicare patients undergoing colectomy or total hip replacement (THR) between January 1, 2007, and December 31, 2010, at US acute care hospitals.

Main Outcomes and Measures  Number of inpatient medical consultations.

Results  More than half of patients undergoing colectomy (91 684) or THR (339 319) received at least 1 medical consultation while hospitalized (69% and 63%, respectively). Median consultant visits from a medicine physician were 9 (interquartile range [IQR], 4-19) for colectomy and 3 for THR (IQR, 2-5). The likelihood of having at least 1 medical consultation varied widely among hospitals (interquartile range [IQR], 50%-91% for colectomy and 36%-90% for THR). For colectomy, settings associated with greater use included nonteaching (adjusted risk ratio [ARR], 1.14 [95% CI, 1.04-1.26]) and for-profit (ARR, 1.10 [95% CI, 1.01-1.20]). Variation in use of medical consultations was greater for colectomy patients without complications (IQR, 47%-79%) compared with those with complications (IQR, 90%-95%). Results stratified by complications were similar for THR.

Conclusions and Relevance  The use of medical consultations varied widely across hospitals, particularly for surgical patients without complications. Understanding the value of medical consultations will be important as hospitals prepare for bundled payments and strive to enhance efficiency.

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Figure 1.
Hospital-Level Probability of Receiving at Least 1 Medical Consultation

A, Hospital-level probability of colectomy patients receiving at least 1 medical consultation. Hospitals are ranked along the x-axis according to their estimated probability of having at least 1 medical visit for colectomy patients. Each point of the black line represents the estimated probability for 1 hospital. The gray area above and below each point represents the 95% CI around the estimate for each hospital. B, Hospital-level probability of total hip replacement (THR) patients receiving at least 1 medical consultation. Hospitals are ranked along the x-axis according to their estimated probability of having at least 1 medical consultation for total hip replacement patients. Each point of the black line represents the estimated probability for 1 hospital. The gray area above and below each point represents the 95% CI around the estimate for each hospital.

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Figure 2.
Hospital-Level Probability of Receiving at Least 1 Medical Consultation, Stratified by Complications

A, Hospital-level probability of colectomy patients receiving at least 1 medical consultation, stratified by complications. The lower and upper borders of each box indicate the 25th and 75th percentiles, respectively. The middle line of each box indicates the median, and the diamond indicates the mean. The ends of the whiskers represent 1.5 × interquartile range, and the circles (when present) represent outliers. B, Hospital-level probability of total hip replacement (THR) patients receiving at least 1 medical consultation, stratified by complications. The lower and upper borders of each box indicate the 25th and 75th percentiles, respectively. The middle line of each box indicates the median, and the diamond indicates the mean. The ends of the whiskers represent 1.5 × interquartile range, and the circles (when present) represent outliers.

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