Wilk Adam S, Chen Lena M
a Department of Health Policy and Management, Rollins School of Public Health , Emory University , Atlanta , GA , USA.
b Center for Health Outcomes and Policy , University of Michigan , Ann Arbor , MI , USA.
Hosp Pract (1995). 2017 Dec;45(5):222-229. doi: 10.1080/21548331.2017.1400369. Epub 2017 Nov 10.
Hospital administrators are seeking to improve efficiency in medical consultation services, yet whether consultants make decisions to provide more or less care is unknown. We examined how medical consultants account for prior consultants' care when determining whether to provide intensive consulting care or sign off in the treatment of complex surgical inpatients. We applied three distinct theoretical frameworks in the interpretation of our results.
We performed a retrospective cohort study of consultants' care intensity, measured alternately using a dummy variable for providing two or more days consulting (versus one) and a continuous measure of total days consulting, with 100% Medicare claims data from 2007-2010. Our analytic samples included consults for beneficiaries undergoing coronary artery bypass grafting (n = 61,785) or colectomy (n = 33,460) in general acute care hospitals. We compared the care intensity of consultants who observed different patterns of consulting care before their initial consults using ordinary least squares regression models at the patient-physician dyad level, controlling for patient comorbidity and many other patient- and physician-level factors as well as hospital region and year fixed effects.
Consultants were less likely to provide intensive consulting care with each additional prior consultant on the case (1.2-1.7 percent) or if a prior consultant rendered intensive consulting care (20.6-21.5 percent) but more likely when prior consults were more concentrated across consultants (2.9-3.1 percent). Effects on consultants' total days consulting were similar.
On average, consultants appeared to calibrate their care intensity for individual patients to maximize their value to all patients. Interventions for improving consulting care efficiency should seek to facilitate (not constrain) consultants' decision-making processes.
医院管理人员试图提高医疗咨询服务的效率，但尚不清楚会诊医生在决定提供更多或更少的护理时会考虑哪些因素。我们研究了在确定是否为复杂外科住院患者提供强化咨询护理或结束护理时，医疗会诊医生如何考虑之前会诊医生的护理情况。我们应用了三种不同的理论框架来解释研究结果。
我们进行了一项回顾性队列研究，以2007年至2010年100%的医疗保险理赔数据，通过使用提供两天或更多天咨询服务（对比一天）的虚拟变量以及咨询总天数的连续测量指标，交替衡量会诊医生的护理强度。我们的分析样本包括在综合急症医院接受冠状动脉搭桥手术（n = 61,785）或结肠切除术（n = 33,460）的受益人的会诊。我们在患者 - 医生二元组层面，使用普通最小二乘法回归模型，比较了在初次会诊前观察到不同会诊护理模式的会诊医生的护理强度，同时控制患者合并症以及许多其他患者和医生层面的因素，以及医院地区和年份固定效应。
随着病例上每增加一名之前的会诊医生，会诊医生提供强化咨询护理的可能性降低（1.2 - 1.7%），或者如果之前的会诊医生提供了强化咨询护理，这种可能性也降低（20.6 - 21.5%），但当之前的会诊更集中于少数会诊医生时，可能性增加（2.9 - 3.1%）。对会诊医生咨询总天数的影响类似。
平均而言，会诊医生似乎会根据个体患者调整护理强度，以实现对所有患者的最大价值。提高咨询护理效率的干预措施应致力于促进（而非限制）会诊医生的决策过程。
