Medical consultations for surgical patients examined amid payment changes

The use of medical consultations for surgical patients varied widely across hospitals, especially among patients without complications, in a study of Medicare beneficiaries undergoing colectomy (to remove all or part of their colon) or total hip replacement (THR).

Internists and medical subspecialists are frequently called on to assess surgical patients and to help manage their care. As payers move toward bundled payments, hospitals need to better understand variations in practice and resources used during patient care.

The authors examined medical consultations for , the factors that influenced their use and practice variation across hospitals. The study used Medicare claims data for 91,684 patients who underwent colectomy at 930 hospitals and 339,319 patients who had THR at 1,589 hospitals from 2007 through 2010.

More than half of the patients undergoing colectomy or THR (69 percent and 63 percent, respectively) had at least one medical consultation while hospitalized. The median number of consult visits was nine for colectomy patients and three for THR. Hospital variation in the use of medical consultations was greater for colectomy patients without complications (47 percent – 79 percent) vs. among those with complications (90 percent – 95 percent). Hospital variation was similar for THR (36 percent – 87 percent among patients without complications vs. 89 percent – 94 percent among those with complications). Nonteaching and for-profit hospitals had greater use of medical consultations for colectomy patients and larger hospitals had greater use of consultations for THR patients.

"Medical consultations are a common component of episodes of inpatient surgical care. Our findings of wide variation in medical consultation use – particularly among patients without – suggest that understanding when medical consultations provide value will be important as hospitals seek to increase their efficiency under bundled payments."

In a related commentary, Gulshan Sharma, M.D., M.P.H., of the University of Texas Medical Branch, Galveston, writes: "Over the past 20 years, the role of the medical consultant for surgical has transformed substantially, from consultant to comanager." Lena M. Chen, M.D., M.S., of the University of Michigan, Ann Arbor, and colleagues wrote in their JAMA Internal Medicine paper.

"While medical consultation has many anticipated benefits, there are downsides as well, including the potential for confusion when multiple opinions are sought; the challenge of decision making when multiple decision makers are included; lack of ownership when problem arises; and the costs associated with soliciting additional input," he continues.

"There is no one fit for all. Decisions on routine use of medical consultation for highly reimbursed procedures should be driven by institutional data on quality and cost," Sharma concludes.

More information: JAMA Intern Med. Published online August 4, 2014. DOI: 10.1001/jamainternmed.2014.3376
JAMA Intern Med. Published online August 4, 2014. DOI: 10.1001/jamainternmed.2014.1499

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