Use of medical consultants for hospitalized surgical patients: an observational cohort study

Abstract

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.

Figure 1

Figure 1A. Hospital-level Probability of Colectomy Patients Receiving at Least One Medicine Visit Hospitals are ranked along the x-axis according to their estimated probability of having at least one medicine visit for colectomy patients. Each point of the black line represents the estimated probability for one hospital. The gray area above and below each point represents the 95% confidence interval around the estimate for each hospital. Figure 1B. Hospital-level Probability of Total Hip Replacement Patients Receiving at Least One Medicine Visit Hospitals are ranked along the x-axis according to their estimated probability of having at least one medicine visit for total hip replacement patients. Each point of the black line represents the estimated probability for one hospital. The gray area above and below each point represents the 95% confidence interval around the estimate for each hospital.

Figure 1

Figure 1A. Hospital-level Probability of Colectomy Patients Receiving at Least One Medicine Visit Hospitals are ranked along the x-axis according to their estimated probability of having at least one medicine visit for colectomy patients. Each point of the black line represents the estimated probability for one hospital. The gray area above and below each point represents the 95% confidence interval around the estimate for each hospital. Figure 1B. Hospital-level Probability of Total Hip Replacement Patients Receiving at Least One Medicine Visit Hospitals are ranked along the x-axis according to their estimated probability of having at least one medicine visit for total hip replacement patients. Each point of the black line represents the estimated probability for one hospital. The gray area above and below each point represents the 95% confidence interval around the estimate for each hospital.

Figure 2

Figure 2A. Hospital-level Probability of Colectomy Patients Receiving at Least One Medicine Visit, Stratified by Complications The lower and upper borders of each box indicate the 25^th and 75^th 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. Figure 2B. Hospital-level Probability of Total Hip Replacement Patients Receiving at Least One Medicine Visit, Stratified by Complications The lower and upper borders of each box indicate the 25^th and 75^th 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.

Figure 2

Figure 2A. Hospital-level Probability of Colectomy Patients Receiving at Least One Medicine Visit, Stratified by Complications The lower and upper borders of each box indicate the 25^th and 75^th 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. Figure 2B. Hospital-level Probability of Total Hip Replacement Patients Receiving at Least One Medicine Visit, Stratified by Complications The lower and upper borders of each box indicate the 25^th and 75^th 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.