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.