Mission and 1-Year Outcomes of a Cardiorenal Subspecialty Consultation Service
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ABSTRACT:
SUBMITTER: Bansal N
PROVIDER: S-EPMC9136897 | biostudies-literature | 2022 Jan
REPOSITORIES: biostudies-literature
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Project description:ImportanceSubspecialty consultation is a frequent, consequential practice in the pediatric inpatient setting. Little is known about factors affecting consultation practices.ObjectivesTo identify patient, physician, admission, and systems characteristics that are independently associated with subspecialty consultation among pediatric hospitalists at the patient-day level and to describe variation in consultation utilization among pediatric hospitalist physicians.Design, setting, and participantsThis retrospective cohort study of hospitalized children used electronic health record data from October 1, 2015, through December 31, 2020, combined with a cross-sectional physician survey completed between March 3 and April 11, 2021. The study was conducted at a freestanding quaternary children's hospital. Physician survey participants were active pediatric hospitalists. The patient cohort included children hospitalized with 1 of 15 common conditions, excluding patients with complex chronic conditions, intensive care unit stay, or 30-day readmission for the same condition. Data were analyzed from June 2021 to January 2023.ExposuresPatient (sex, age, race and ethnicity), admission (condition, insurance, year), physician (experience, anxiety due to uncertainty, gender), and systems (hospitalization day, day of week, inpatient team, and prior consultation) characteristics.Main outcomes and measuresThe primary outcome was receipt of inpatient consultation on each patient-day. Risk-adjusted consultation rates, expressed as number of patient-days consulting per 100, were compared between physicians.ResultsWe evaluated 15 922 patient-days attributed to 92 surveyed physicians (68 [74%] women; 74 [80%] with ≥3 years' attending experience) caring for 7283 unique patients (3955 [54%] male patients; 3450 [47%] non-Hispanic Black and 2174 [30%] non-Hispanic White patients; median [IQR] age, 2.5 ([0.9-6.5] years). Odds of consultation were higher among patients with private insurance compared with those with Medicaid (adjusted odds ratio [aOR], 1.19 [95% CI, 1.01-1.42]; P = .04) and physicians with 0 to 2 years of experience vs those with 3 to 10 years of experience (aOR, 1.42 [95% CI, 1.08-1.88]; P = .01). Hospitalist anxiety due to uncertainty was not associated with consultation. Among patient-days with at least 1 consultation, non-Hispanic White race and ethnicity was associated with higher odds of multiple consultations vs non-Hispanic Black race and ethnicity (aOR, 2.23 [95% CI, 1.20-4.13]; P = .01). Risk-adjusted physician consultation rates were 2.1 times higher in the top quartile of consultation use (mean [SD], 9.8 [2.0] patient-days consulting per 100) compared with the bottom quartile (mean [SD], 4.7 [0.8] patient-days consulting per 100; P < .001).Conclusions and relevanceIn this cohort study, consultation use varied widely and was associated with patient, physician, and systems factors. These findings offer specific targets for improving value and equity in pediatric inpatient consultation.
| S-EPMC10011930 | biostudies-literature
Project description:ImportanceHigh use of subspecialty care is an important source of health care spending. Medical subspecialty care in particular may duplicate the scope of practice of the primary attending physicians for patients hospitalized for medical conditions. Under value-based payments, which aim to control overall spending during an episode of hospitalization (including Part B physician fees), subspecialty consultations may be a target for hospitals working to reduce costs.ObjectivesTo measure the use of subspecialty consultation for Medicare beneficiaries hospitalized for nonsurgical conditions; to compare payments for consultative and nonconsultative care, adjusted for case mix and demographics; and to measure variation in payments across hospital referral regions (HRRs).Design, setting, and participantsThis retrospective cross-sectional study included a 15% random sample of Medicare fee-for-service beneficiaries enrolled in Parts A and B and identified all discharges after acute care hospital stays for nonsurgical conditions from January 1 through December 31, 2014. A total of 735 627 discharges were included. The analyses were conducted from December 1, 2017, through February 12, 2019. Total Part B payments were extrapolated to the population of Medicare fee-for-service beneficiaries.Main outcomes and measuresProbability of any consultation during a hospitalization was estimated using logistic regression. The number of consultations per stay and the number of consultative visits per hospital day were estimated using Poisson regression. Part B payments for consultative and nonconsultative care were estimated using generalized linear regression with gamma-log link. All models were adjusted for patient demographics and case mix. Payment models also included HRR fixed effects.ResultsA total of 735 627 discharges from 4534 hospitals in 2014 were included in the analysis (41.2% men and 58.8% women; mean [SD] age, 79.6 [8.9] years; 84.7% white, 10.1% black, and 5.2% other race). After adjusting for patient case mix and demographics, a 6-fold variation between the top and bottom quintiles of hospitals (relative difference, $401 [95% CI, $368-$434]) and HRRs (relative difference, $363 [95% CI, $337-$389]) was found in payments per stay for consultative care. Part B payments for consultative care by medical subspecialists accounted for 41.3% of payments for physician visits during hospitalization and totaled $1.3 billion in 2014.Conclusions and relevanceThe substantial variation in the use of subspecialty consultative care suggests potential opportunities for cost savings.
| S-EPMC6450334 | biostudies-literature
Project description:BackgroundTo evaluate the clinical features and outcomes of acute cardiorenal syndrome type-5 in patients with severe sepsis and septic shock.MethodsHistorical cohort study of all adult patients with severe sepsis and septic shock admitted to the intensive care units (ICU) at Mayo Clinic Rochester from January 1, 2007 through December 31, 2014. Patients with prior renal or cardiac dysfunction were excluded. Patients were divided into groups with and without cardiorenal syndrome type-5. Acute Kidney Injury (AKI) was defined by both serum creatinine and urine output criteria of the AKI Network and the cardiac injury was determined by troponin-T levels. Outcomes included in-hospital mortality, ICU and hospital length of stay, and one-year survival.ResultsOf 602 patients meeting the study inclusion criteria, 430 (71.4%) met criteria for acute cardiorenal syndrome type-5. Patients with cardiorenal syndrome type-5 had higher severity of illness, greater vasopressor and mechanical ventilation use. Cardiorenal syndrome type-5 was associated higher unadjusted in-hospital mortality, ICU and hospital lengths of stay, and lower one-year survival. When adjusted for age, gender, severity of illness and mechanical ventilation, cardiorenal syndrome type-5 was independently associated with 1.7-times greater odds of in-hospital mortality (p = .03), but did not predict one-year survival (p = .06) compared to patients without cardiorenal syndrome.ConclusionsIn sepsis, acute cardiorenal syndrome type-5 is associated with worse in-hospital mortality compared to patients without cardiorenal syndrome.
| S-EPMC5760054 | biostudies-literature
Project description:BackgroundOnline health communities have given rise to a new e-service known as online medical consultations (OMCs), enabling remote interactions between physicians and patients. To address challenges, such as patient information overload and uneven distribution of physician visits, online health communities should develop OMC-oriented recommenders.ObjectiveWe aimed to comprehensively investigate what paradigms lead to the success of OMC-oriented recommendations.MethodsA literature search was conducted through e-databases, including PubMed, ACM Digital Library, Springer, and ScienceDirect, from January 2011 to December 2023. This review included all papers directly and indirectly related to the topic of health care-related recommendations for online services.ResultsThe search identified 611 articles, of which 26 (4.3%) met the inclusion criteria. Despite the growing academic interest in OMC recommendations, there remains a lack of consensus among researchers on the definition of e-service-oriented recommenders. The discussion highlighted 3 key factors influencing recommender success: features, algorithms, and metrics. It advocated for moving beyond traditional e-commerce-oriented recommenders to establish an innovative theoretical framework for e-service-oriented recommenders and addresses critical technical issues regarding 2-sided personalized recommendations.ConclusionsThis review underscores the essence of e-services, particularly in knowledge- and labor-intensive domains such as OMCs, where patients seek interpretable recommendations due to their lack of domain knowledge and physicians must balance their energy levels to avoid overworking. Our study's findings shed light on the importance of customizing e-service-oriented personalized recommendations to meet the distinct expectations of 2-sided users considering their cognitive abilities, decision-making perspectives, and preferences. To achieve this, a paradigm shift is essential to develop unique attributes and explore distinct content tailored for both parties involved.
| S-EPMC11322685 | biostudies-literature
Project description:BackgroundConsultation-Liaison Psychiatry (CLP) provides services for patients with medical-psychiatric comorbidity at the general hospital. Referral satisfaction is considered as one of the most important outcome measures of CLP interventions. Our aim was to assess the levels of satisfaction with the CLP service amongst medical staff at a university hospital in Denmark.MethodsMedical staff answered an online survey regarding their experience with different aspects of inpatient and outpatient CLP services.ResultsThere were 152 responses from 16 medical units, with a survey return rate above 85%. Measured on a 5-point Likert scale, there was a median rating of 4 in response to questions regarding communication and organizational aspects, a median rating of 5 in response to questions regarding overall evaluation of the CLP service on both inpatient and outpatient questionnaire. The questions regarding treatment quality were rated with a median of 4 on the inpatient questionnaire and 2 of the outpatient questionnaire items, and with a median of 5 on 2 outpatient items. Physicians´ evaluations were statistically more positive than nurses´. As a group, respondents already employed before the CLP unit was established and those who used the CLP services more were statistically significantly more satisfied then respondents employed after the establishment of the CLP unit and those who used the CLP service less.ConclusionThe CLP services were positively appreciated and considered to be valuable among medical hospital staff. We believe that Consultation-Liaison Psychiatry deserves further help to implement and expand its services in general hospital settings. In addition, our results underline the feasibility of surveys as quality measures of clinical care.
| S-EPMC8167950 | biostudies-literature
Project description:Access to specialist services is limited by wait times and geographic availability. Champlain Building Access to Specialist Advice (BASE) has been implemented in our service region to facilitate access to specialists by primary care providers (PCPs). Through a secure web-based system, PCPs are able to send eConsults instead of requesting a formal in-office consultation.Urology eConsults completed through the Champlain BASE service from March 2013 to January 2015 were analyzed. Each consult was characterized in regard to the type of question asked by the referring physician and the clinical content of the referral. Using the mandatory close-out surveys, we analyzed rates of referral avoidance, physician satisfaction, and overall impact on patient care.Of 190 eConsultations, 70% were completed in less than 10 minutes. The most common clinical questions related to the interpretation of imaging reports (16%) and tests to choose for investigating a condition (15%). The most common diagnoses were hematuria (13%) and renal mass (8%). In 35% of cases, referral to a urologist had originally been contemplated and was avoided. In 8% of cases, a PCP did not believe a consultation was initially needed, but a referral was ultimately initiated after the eConsultation.Our study shows that although certain clinical presentations still require a formal in-person urological consultation, eConsultations can potentially reduce unnecessary clinic visits while identifying patients who may benefit from early urological consultation. Through both these mechanisms, we may improve timely access to urologists.
| S-EPMC5542837 | biostudies-other
Project description:BackgroundsEarly integration of palliative care for terminally ill non-cancer patients improves quality of life. However, there are scanty data on Palliative Care Consultation Service (PCCS) among non-cancer patients.MethodsIn this 9-year observational study Data were collected from the Hospice-Palliative Clinical Database (HPCD) of Taichung Veterans General Hospital (TCVGH). Terminally ill non-cancer patients with 9 categories of diagnoses who received PCCS during 2011 to 2019 were enrolled. Trend analysis was performed to evaluate differences in categories of diagnosis throughout study period, duration of PCCS, patient outcomes, DNR declaration, awareness of disease by patients and families before and after PCCS.ResultsIn total, 536 non-cancer patients received PCCS from 2011 to 2019 with an average age of 70.7 years. The average duration of PCCS was 18.4 days. The distributions of age, gender, patient outcomes, family's awareness of disease before PCCS, and patient's awareness of disease after PCCS were significantly different among the diagnoses. Organic brain disease and Chronic kidney disease (CKD) were the most prevalent diagnoses in patients receiving PCCS in 2019. For DNR declaration, the percentage of patients signing DNR before PCCS remained high throughout the study period (92.8% in 2019). Patient outcomes varied according to the disease diagnoses.ConclusionThis 9-year observational study showed that the trend of PCCS among non-cancer patients had changed over the duration of the study. An increasing number of terminally ill non-cancer patients received PCCS during late life, thereby increasing the awareness of disease for both patients and families, which would tend to better prepare terminally ill patients for end-of-life as they may consider DNR consent. Early integration of PCCS into ordinary care for terminally non-cancer patients is essential for better quality of life.
| S-EPMC8614035 | biostudies-literature
Project description:Background and aimThe current COVID-19 pandemic scenario has driven surgical departments to a transformation. The worldwide spread of the disease has led to a public health quarantine where health care professionals are at high risk of infection. In this context, telemedicine has been promoted and scaled up to reduce the risk of transmission. This study aims to demonstrate that a combined framework based on telematics and in-person clinical encounter not only ensures medical care but the safety of healthcare professionals and patients.Material and methodDescriptive observational study on the follow-up of patients during the COVID19 Pandemic, combining telephone and traditional.ResultsA total of 5031 telephone calls were made, differentiating between medical referrals, specialized primary care visits, and outpatient consultation. They were classified as successful, required an in-person visit, or no successful telephone contact. Furthermore, we divided them into 2 groups: resolved and unresolved. 53% of all telematic visits were successful.ConclusionsTelematic medical systems are a feasible option in a orthopedics department and an interesting resource to preserve once the pandemic is resolved. Future lines of research should be opened to improve system success, analyze its cost-effectiveness ratio, and correct any legal conflicts that may exist.
| S-EPMC7832733 | biostudies-literature
Project description:Background and aimThe current COVID-19 pandemic scenario has driven surgical departments to a transformation.The worldwide spread of the disease has led to a public health quarantine where health care professionals are at high risk of infection. In this context, telemedicine has been promoted and scaled up to reduce the risk of transmission. This study aims to demonstrate that a combined framework based on telematics and in-person clinical encounter not only ensures medical care but the safety of healthcare professionals and patients.Material and methodDescriptive observational study on the follow-up of patients during the COVID19 Pandemic, combining telephone and traditional.ResultsA total of 5031 telephone calls were made, differentiating between medical referrals, specialised primary care visits, and outpatient consultation.They were classified as successful, required an in-person visit, or no successful telephone contact. Furthermore, we divided them into 2 groups: resolved and unresolved.53% of all telematic visits were successful.ConclusionsTelematic medical systems are a feasible option in a orthopedics department and an interesting resource to preserve once the pandemic is resolved. Future lines of research should be opened to improve system success, analyze its cost-effectiveness ratio, and correct any legal conflicts that may exist.
| S-EPMC8045449 | biostudies-literature
Project description:BackgroundSubspecialty consultation in inpatient care is increasing. Teaching by subspecialty fellows in a consultation setting may be an important source of work-based learning for students and residents. However, teaching and evaluation of learners in this context may be challenging due to personal and systems-based barriers.ObjectiveWe developed and evaluated a framework designed to overcome barriers to teaching and to improve fellow teaching skills during inpatient consultation.MethodsThe PARTNER (Partner with resident, Assess the learner, Reinforce positives, Teaching objectives, New knowledge, Execute recommendations, Review) framework was delivered to rheumatology and pulmonary and critical care medicine fellows at 3 academic medical centers as part of a 2-session Fellow as Clinical Teacher (FACT) curriculum. Fellows' teaching skills were evaluated using an objective structured teaching exercise (OSTE) pre- and postcurriculum, and at the end of the academic year. Self-assessment surveys were used to evaluate fellows' self-perception of teaching skills.ResultsTwelve of 16 eligible fellows (75%) participated in the program and completed 73 OSTE cases. Teaching skills measured by OSTEs and self-assessment surveys improved after administration of the FACT curriculum. There was no significant skill decay at the end-of-year evaluation. The curriculum was rated highly, and 73% (8 of 11) of fellows stated they would teach more frequently as a result of the intervention.ConclusionsThe FACT curriculum was practical and feasible, and significantly improved fellows' teaching skills teaching during inpatient consultation.
| S-EPMC5476386 | biostudies-literature