Clinical question: How are medical consultants used for hospitalized surgical patients, and how does this vary among regions and hospitals in the U.S.?
Background: Reimbursement for surgical procedures is moving toward bundled payments, making it increasingly important to understand the use of resources in order to improve efficiency and quality of care.
Study design: Observational, retrospective, cohort study.
Setting: Fee-for-service Medicare patients undergoing colectomy or total hip replacement (THR) at U.S. acute care hospitals.
Synopsis: Using the Medicare Provider Analysis and Review (MEDPAR) File, the Carrier File, and the 2007 American Hospital Association’s annual survey, researchers evaluated a sample of 91,684 colectomy patients at 930 hospitals and 339,319 THR patients at 1,589 hospitals between the ages of 65 and 99 who were enrolled in Medicare parts A and B between 2007 and 2010. Sixty-nine percent of colectomy patients saw a consultant (50% medicine and 56% specialists). Sixty-three percent of THR patients saw a consultant (53% medicine and 24% specialists).
Patient factors for consults included older age, comorbidities, and nonelective admission. Hospital factors for consults included Midwest location, nonteaching, for-profit status, and hospital size. Greater use of consultants was associated with higher rates of post-operative complications.
Additional research on the association between mortality after complications (including type and timing) and number of consultants may help to improve future efficiency and outcomes. Creating a consensus about the use of medical consultants in healthy patients would also be beneficial.
Limitations of the study include a lack of detail on consult indications, unknown effect of pre-operative outpatient medical consults, major differences in median visits by site and surgery type, and the sole use of administrative claims data.
Bottom line: With the procedural fee for service changing to bundled payments, guidelines may be necessary for appropriate use of consultants, to improve both efficiency and quality of care provided by hospitals.
Citation: Chen LM, Wilk AS, Thumma JR, Birkmeyer JD, Banerjee M. Use of medical consultants for hospitalized surgical patients: an observational cohort study. JAMA Intern Med. 2014;174(9):1470-1477.