Diagnostic test restraint and the specialty consultation.

OBJECT

To assess the effect consultants had on the diagnostic process in the management of patients admitted to the medical service of a university hospital.

DESIGN

Cohort study utilizing prospective evaluation by residents, retrospective chart review, and direct communication with the patient, a family member, or the patient's physician one year after admission to the hospital.

SETTING

The medical inpatient service of an urban university hospital.

PATIENTS

The 580 patients admitted to the medical service during one month in 1984 for whom complete data were available.

MAIN RESULTS

Sixty-three percent of the patients had consultations. Seventy percent (198/284) of the patients admitted by generalists had consultations, while 57% (170/296) of the patients admitted by subspecialists had consultations. Of the 1,422 major diagnostic tests performed on these patients, 504 (35%) were first recommended by consultants, and the consultants recommended cancellation of only ten major diagnostic tests. Patients who were seen by consultants had a length of stay that was more than double that of patients not seen by consultants. Consultation was associated with prolonged stay when patients were stratified by important clinical variables and remained an important independent factor in a multivariate model. The prolongation of hospitalization was principally due to delays in scheduling and interpreting sophisticated tests recommended by the consultants. When stratified into prognostically similar clinical groupings, there was no significant difference in in-hospital mortality between patients seen and those not seen by a consultant.

CONCLUSION

Efforts to foster diagnostic restraint in the management of hospitalized patients should be broadened to include attention to the specialty consultation process.