Research
Original Investigation
Use of Medical Consultants for Hospitalized Surgical Patients An Observational Cohort Study Lena M. Chen, MD, MS; Adam S. Wilk, BA; Jyothi R. Thumma, MPH; John D. Birkmeyer, MD; Mousumi Banerjee, PhD
IMPORTANCE Payments around episodes of inpatient surgery vary widely among hospitals.
Invited Commentary page 1477
As payers move toward bundled payments, understanding sources of variation, including use of medical consultants, is important.
Author Audio Interview at jamainternalmedicine.com
OBJECTIVE To describe the use of medical consultations for hospitalized surgical patients,
Supplemental content at jamainternalmedicine.com
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.
CME Quiz at jamanetworkcme.com and CME Questions page 1528
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. JAMA Intern Med. 2014;174(9):1470-1477. doi:10.1001/jamainternmed.2014.3376 Published online August 4, 2014.
A
s the Centers for Medicare & Medicaid Services (CMS) and others move to bundled payments around longitudinal episodes of care, hospitals are facing a greater need to understand practice variation and areas of excess resource use within episodes of care. In the case of inpatient surgery, for example, one recent study suggests that episodebased payments for surgery vary as much as 10% to 40% after adjusting for case mix and price.1 For some procedures, variation in episode-based payments is driven by multiple factors, including readmissions, use of home health, skilled nursing services, and other components of postdischarge care.1,2 Another source of variation is the use of professional services, including the use of medical consultants. Internists and medical subspecialists are frequently called on to provide pre1470
Author Affiliations: Author affiliations are listed at the end of this article. Corresponding Author: Lena M. Chen, MD, MS, Division of General Medicine, University of Michigan, North Campus Research Complex, 2800 Plymouth Rd, Bldg 16, Room 407E, Ann Arbor, MI 48109-2800 ([email protected]).
operative assessments of risk and to provide advice on how to reduce these risks. Medical consultants may also be employed for more routine comanagement, caring for surgical patients’ chronic medical conditions such as diabetes and hypertension for the duration of the hospital stay. Finally, medical consultants often assist in the care of patients with certain complications after surgery, including acute kidney injury, surgical site infections, and postoperative myocardial infarction. Although prior work suggests a long-term trend toward increased use of medical consultants for comanagement of surgical patients,3 variation in the use of consultations for hospitalized surgical patients has not been studied carefully. In this context, we used national Medicare data to explore the use of medical consultations around inpatient surgery, factors as-
JAMA Internal Medicine September 2014 Volume 174, Number 9
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a Ndsu Library Periodicals User on 05/31/2015
jamainternalmedicine.com
Medical Consultants for Hospitalized Surgical Patients
sociated with increased use, and variation in practice patterns across hospitals.
Original Investigation Research
patients who underwent colectomy at 930 hospitals and 339 319 patients who underwent THR at 1589 hospitals.
Characterizations of Medical Consultations
Methods This study is part of a larger project that was reviewed by the institutional review board of the University of Michigan, which found this study to be exempt from its oversight.
Data Sources and Study Population To identify inpatient medical visits, we used the Medicare Provider Analysis and Review (MedPAR) File and the Carrier File (100% for our cohort). We also used the American Hospital Association (AHA) Annual Survey 2007 to identify hospital characteristics.4 From these complete Medicare claims data, we created a cohort of elderly fee-for-service Medicare beneficiaries who underwent colectomy or total hip replacement (THR) at a nonfederal hospital from January 2007 to December 2010. We chose to examine these 2 procedures because they are among the top 10 principal surgical procedures performed on Medicare patients. Colectomy is also performed on patients likely to have multiple medical comorbidities that may be managed with or without a medical consultant. Total hip replacement is one of the procedures included in CMS’ bundled payment demonstration project.5 We used procedure codes from the International Classification of Diseases, Ninth Revision (ICD-9) to define colectomy (procedure codes 45.73-45.76, 45.79, and 45.81-45.83) and THR (procedure code 81.51), identifying 497 655 colectomy patients and 567 646 THR patients. We excluded patients admitted to facilities other than general acute care hospitals for these index procedures and those admitted to hospitals we could not link to AHA data. We also excluded patients not enrolled in Medicare fee-for-service Parts A and B for the duration of their hospitalizations and patients younger than 65 years or older than 99 years at the time of their procedure. To increase the clinical homogeneity of our samples, we applied several additional exclusion criteria. We excluded colectomy patients with no cancer diagnosis (ie, diagnosis codes 153.0-153.9 and 154.0) and THR patients with a hip fracture diagnosis (ie, diagnosis codes 820.0-820.3, 820.8, and 820.9). Finally, we excluded patients whose inpatient stays spanned 2 calendar years because we did not have complete claims data for these patients (2975 patients for colectomy and 1752 patients for THR). To increase the reliability of our estimates and because hospitals varied widely in the number of procedures performed during the study period (ie, range of 1-446 for colectomy and 1-5084 for THR), we also excluded patients if their hospitals had fewer than 10 cases in any year during our study period. Similar exclusion criteria have been chosen in prior studies to reduce statistical artifact.6 During the study period, 2186 hospitals with 48 306 patients performed fewer than 10 colectomies per year and 1321 hospitals with 32 434 patients performed fewer than 10 THRs per year. After applying all exclusion criteria, our final analytic samples included 91 684 jamainternalmedicine.com
Our primary outcome was having at least 1 inpatient medical consultation at any time during hospitalization for colectomy or THR. We defined inpatient consultations using Current Procedural Terminology (CPT) codes (99221-99223, 9929199292, 99251-99255, and 99231-99233). In most cases, these codes do not allow us to distinguish between an attending vs consulting medicine physician. In defining inpatient consultations for our cohort, we included all of these codes because clinical practice and Medicare coding regulations make little distinction between care for a surgical inpatient that is provided by an attending vs consulting medicine physician. We included consultations that had been performed by health care providers in general medicine (general practice, family practice, internal medicine, or geriatric medicine), oncology (medical oncology or hematology oncology), cardiology, endocrinology, gastroenterology, infectious disease, nephrology, physical medicine and rehabilitation, pulmonary disease and/or critical care, or other medical subspecialties (allergy and immunology, dermatology, hematology, neurology, pain management, or rheumatology). Using a previously validated methodology,7,8 we defined 8 common postoperative, inpatient surgical complications with ICD-9 diagnosis and procedure codes (see eAppendix in the Supplement). These postoperative complications included pulmonary failure, pneumonia, myocardial infarction, deep venous thrombosis and pulmonary embolism, acute renal failure, hemorrhage, surgical site infection, and gastrointestinal tract hemorrhage.
Statistical Analyses We first characterized the types of consultations ordered for patients undergoing colectomy or THR. For each specialty type, we identified the proportion of patients with at least 1 consultation and the median number of visits observed when at least 1 consultation had been ordered. We also described the proportion of patients who received medical comanagement (using the previously validated definition of 70% or more of inpatient days with an evaluation and management claim from a medicine physician).3 Hierarchical logistic regression analyses were used to identify patient and hospital factors associated with ordering at least 1 perioperative medical consultation (binary outcome). Specifically, we used generalized linear mixed model (GLMMIX) with logit link to account for the clustering of patients within hospitals while assessing the effect of patient characteristics (sex, age group, race, number of comorbidities, elective admission type) and hospital characteristics (hospital beds [≥500, 350-499, 200-349,
Original Investigation
Use of Medical Consultants for Hospitalized Surgical Patients An Observational Cohort Study Lena M. Chen, MD, MS; Adam S. Wilk, BA; Jyothi R. Thumma, MPH; John D. Birkmeyer, MD; Mousumi Banerjee, PhD
IMPORTANCE Payments around episodes of inpatient surgery vary widely among hospitals.
Invited Commentary page 1477
As payers move toward bundled payments, understanding sources of variation, including use of medical consultants, is important.
Author Audio Interview at jamainternalmedicine.com
OBJECTIVE To describe the use of medical consultations for hospitalized surgical patients,
Supplemental content at jamainternalmedicine.com
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.
CME Quiz at jamanetworkcme.com and CME Questions page 1528
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. JAMA Intern Med. 2014;174(9):1470-1477. doi:10.1001/jamainternmed.2014.3376 Published online August 4, 2014.
A
s the Centers for Medicare & Medicaid Services (CMS) and others move to bundled payments around longitudinal episodes of care, hospitals are facing a greater need to understand practice variation and areas of excess resource use within episodes of care. In the case of inpatient surgery, for example, one recent study suggests that episodebased payments for surgery vary as much as 10% to 40% after adjusting for case mix and price.1 For some procedures, variation in episode-based payments is driven by multiple factors, including readmissions, use of home health, skilled nursing services, and other components of postdischarge care.1,2 Another source of variation is the use of professional services, including the use of medical consultants. Internists and medical subspecialists are frequently called on to provide pre1470
Author Affiliations: Author affiliations are listed at the end of this article. Corresponding Author: Lena M. Chen, MD, MS, Division of General Medicine, University of Michigan, North Campus Research Complex, 2800 Plymouth Rd, Bldg 16, Room 407E, Ann Arbor, MI 48109-2800 ([email protected]).
operative assessments of risk and to provide advice on how to reduce these risks. Medical consultants may also be employed for more routine comanagement, caring for surgical patients’ chronic medical conditions such as diabetes and hypertension for the duration of the hospital stay. Finally, medical consultants often assist in the care of patients with certain complications after surgery, including acute kidney injury, surgical site infections, and postoperative myocardial infarction. Although prior work suggests a long-term trend toward increased use of medical consultants for comanagement of surgical patients,3 variation in the use of consultations for hospitalized surgical patients has not been studied carefully. In this context, we used national Medicare data to explore the use of medical consultations around inpatient surgery, factors as-
JAMA Internal Medicine September 2014 Volume 174, Number 9
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a Ndsu Library Periodicals User on 05/31/2015
jamainternalmedicine.com
Medical Consultants for Hospitalized Surgical Patients
sociated with increased use, and variation in practice patterns across hospitals.
Original Investigation Research
patients who underwent colectomy at 930 hospitals and 339 319 patients who underwent THR at 1589 hospitals.
Characterizations of Medical Consultations
Methods This study is part of a larger project that was reviewed by the institutional review board of the University of Michigan, which found this study to be exempt from its oversight.
Data Sources and Study Population To identify inpatient medical visits, we used the Medicare Provider Analysis and Review (MedPAR) File and the Carrier File (100% for our cohort). We also used the American Hospital Association (AHA) Annual Survey 2007 to identify hospital characteristics.4 From these complete Medicare claims data, we created a cohort of elderly fee-for-service Medicare beneficiaries who underwent colectomy or total hip replacement (THR) at a nonfederal hospital from January 2007 to December 2010. We chose to examine these 2 procedures because they are among the top 10 principal surgical procedures performed on Medicare patients. Colectomy is also performed on patients likely to have multiple medical comorbidities that may be managed with or without a medical consultant. Total hip replacement is one of the procedures included in CMS’ bundled payment demonstration project.5 We used procedure codes from the International Classification of Diseases, Ninth Revision (ICD-9) to define colectomy (procedure codes 45.73-45.76, 45.79, and 45.81-45.83) and THR (procedure code 81.51), identifying 497 655 colectomy patients and 567 646 THR patients. We excluded patients admitted to facilities other than general acute care hospitals for these index procedures and those admitted to hospitals we could not link to AHA data. We also excluded patients not enrolled in Medicare fee-for-service Parts A and B for the duration of their hospitalizations and patients younger than 65 years or older than 99 years at the time of their procedure. To increase the clinical homogeneity of our samples, we applied several additional exclusion criteria. We excluded colectomy patients with no cancer diagnosis (ie, diagnosis codes 153.0-153.9 and 154.0) and THR patients with a hip fracture diagnosis (ie, diagnosis codes 820.0-820.3, 820.8, and 820.9). Finally, we excluded patients whose inpatient stays spanned 2 calendar years because we did not have complete claims data for these patients (2975 patients for colectomy and 1752 patients for THR). To increase the reliability of our estimates and because hospitals varied widely in the number of procedures performed during the study period (ie, range of 1-446 for colectomy and 1-5084 for THR), we also excluded patients if their hospitals had fewer than 10 cases in any year during our study period. Similar exclusion criteria have been chosen in prior studies to reduce statistical artifact.6 During the study period, 2186 hospitals with 48 306 patients performed fewer than 10 colectomies per year and 1321 hospitals with 32 434 patients performed fewer than 10 THRs per year. After applying all exclusion criteria, our final analytic samples included 91 684 jamainternalmedicine.com
Our primary outcome was having at least 1 inpatient medical consultation at any time during hospitalization for colectomy or THR. We defined inpatient consultations using Current Procedural Terminology (CPT) codes (99221-99223, 9929199292, 99251-99255, and 99231-99233). In most cases, these codes do not allow us to distinguish between an attending vs consulting medicine physician. In defining inpatient consultations for our cohort, we included all of these codes because clinical practice and Medicare coding regulations make little distinction between care for a surgical inpatient that is provided by an attending vs consulting medicine physician. We included consultations that had been performed by health care providers in general medicine (general practice, family practice, internal medicine, or geriatric medicine), oncology (medical oncology or hematology oncology), cardiology, endocrinology, gastroenterology, infectious disease, nephrology, physical medicine and rehabilitation, pulmonary disease and/or critical care, or other medical subspecialties (allergy and immunology, dermatology, hematology, neurology, pain management, or rheumatology). Using a previously validated methodology,7,8 we defined 8 common postoperative, inpatient surgical complications with ICD-9 diagnosis and procedure codes (see eAppendix in the Supplement). These postoperative complications included pulmonary failure, pneumonia, myocardial infarction, deep venous thrombosis and pulmonary embolism, acute renal failure, hemorrhage, surgical site infection, and gastrointestinal tract hemorrhage.
Statistical Analyses We first characterized the types of consultations ordered for patients undergoing colectomy or THR. For each specialty type, we identified the proportion of patients with at least 1 consultation and the median number of visits observed when at least 1 consultation had been ordered. We also described the proportion of patients who received medical comanagement (using the previously validated definition of 70% or more of inpatient days with an evaluation and management claim from a medicine physician).3 Hierarchical logistic regression analyses were used to identify patient and hospital factors associated with ordering at least 1 perioperative medical consultation (binary outcome). Specifically, we used generalized linear mixed model (GLMMIX) with logit link to account for the clustering of patients within hospitals while assessing the effect of patient characteristics (sex, age group, race, number of comorbidities, elective admission type) and hospital characteristics (hospital beds [≥500, 350-499, 200-349,
