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    Original Investigation
    Health Policy
    February 21, 2020

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

    Author Affiliations
    • 1Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts
    • 2Division for Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
    • 3Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
    • 4Center for Medicare & Medicaid Innovation, Centers for Medicare & Medicaid Services, Baltimore, Maryland
    • 5Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
    JAMA Netw Open. 2020;3(2):e1921750. doi:10.1001/jamanetworkopen.2019.21750
    Key Points español 中文 (chinese)

    Question  Are hospitalized Medicare beneficiaries who are exposed to higher rates of specialty consultation associated with outcomes such as greater resource use, length of stay, readmissions, and mortality?

    Findings  In this cohort study of 711 654 inpatient medical admissions, hospitalists who used specialty consultation more than their colleagues at the same institution used more resources without a difference in patient mortality. Compared with patients treated by other hospitalists, the patients of high-consulting hospitalists had longer lengths of stay, were less likely to go home, and were more likely to see a specialist within 90 days after discharge, but there was no significant difference in their mortality at 30 days or their likelihood of all-cause readmission.

    Meaning  A decrease in the frequency of specialty consultation may be an opportunity for hospitals to reduce complexity and costs in patient care without adversely affecting patients.


    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.