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. 2020 Feb 5;3(2):e1921750.
doi: 10.1001/jamanetworkopen.2019.21750.

Association of Variation in Consultant Use Among Hospitalist Physicians With Outcomes Among Medicare Beneficiaries

Jennifer P Stevens  1   2 , Laura A Hatfield  3 , David J Nyweide  4 , Bruce Landon  1   3   5
Affiliations

Association of Variation in Consultant Use Among Hospitalist Physicians With Outcomes Among Medicare Beneficiaries

Jennifer P Stevens et al. JAMA Netw Open. .

Abstract

Importance: Evidence is lacking on the consequences of high rates of inpatient consultation.

Objective: To examine outcomes and resource use of patients cared for by hospitalists who use more inpatient consultation than their colleagues.

Design, setting, and participants: A retrospective cohort study of medical admissions to hospitalists among fee-for-service Medicare beneficiaries was conducted. Hospitalist consultation tendency was identified from January 1, 2013, to December 31, 2014; admissions were calculated in 2013; and outcomes were measured in 2014. Data were analyzed from January 31, 2017, to May 9, 2019. A total of 711 654 admissions with patients receiving care from 14 584 hospitalists at 737 hospitals were included.

Exposure: Admission to high-consulting hospitalists, considered to be those who were in the top 25% of the distribution of consulting frequency at their own hospital (adjusted for patient case mix).

Main outcomes and measures: Outcomes included length of stay, Medicare Part B inpatient charges, discharge destination, all-cause 7- and 30-day readmissions, 90-day outpatient specialist visits, and 30-day mortality.

Results: The 711 654 hospital admissions included 408 489 women (57.4%); mean (SD) age of the population was 80 (8.5) years. Length of stay of patients cared for by high-consulting hospitalists was longer compared with other hospitalists (adjusted incidence rate ratio, 1.04; 95% CI, 1.03-1.05). The admissions resulted in a mean of $137.91 (95% CI, $118.89-$156.93) more in Medicare Part B charges and were less likely to end with the patient going home (adjusted odds ratio [aOR], 0.96; 95% CI, 0.94-0.98) compared with patients cared for by other hospitalists in the cohort. Patients cared for by high-consulting hospitalists also were 7% more likely than patients cared for by other hospitalists to see an outpatient specialist at 90 days (aOR 1.07; 95% CI, 1.05-1.09), with no significant differences in 30-day mortality (aOR 1.01, 95% CI, 0.98-1.03) or readmissions (7-day readmissions: aOR 1.01; 95% CI, 0.98-1.03; 30-day readmissions: aOR, 1.01; 95% CI, 0.99-1.03).

Conclusions and relevance: Hospitalists who obtain consultations more than their colleagues at the same institution were associated with greater use of health care resources without apparent mortality benefit. Further investigation should identify whether reducing high rates of consultation can reduce resource use without harming patients.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Stevens reported receiving grants from the Agency for Healthcare Research and Quality and the Doris Duke Charitable Foundation during the conduct of the study; and receiving royalties from UpToDate as well as for the textbook Understanding Healthcare Delivery Science from McGraw Hill Medical. Dr Hatfield reported receiving personal fees from Beth Israel Deaconess Medical Center during the conduct of the study; personal fees from Cambridge Health Alliance, Mathematica Policy Research, Greylock McKinnon Associates, and RAND outside the submitted work; and grants and personal fees from the Laura and John Arnold Foundation. No other disclosures were reported.

Figures

Figure.
Figure.. Within-Hospital Distribution of Residual Consultations per Admission
Each line spans from a hospital's 25th to 75th percentile in the distribution of residual consults per admission (across hospitalists). The residuals come from the model fit to 2013 admissions, adjusted for diagnosis related group. The solid points mark the hospital medians. The national mean of 1.1 consultations per admission (horizontal dotted line) was added to each value to aid interpretation of the scale.
See this image and copyright information in PMC

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