Division of Pediatric Hospital Medicine.
Center for Value-Based Care Research, Cleveland Clinic, Cleveland, Ohio.
Hosp Pediatr. 2024 Sep 1;14(9):782-789. doi: 10.1542/hpeds.2023-007589.
Inpatient subspecialty consultation is often medically necessary but in some cases may represent overuse. While pediatric consultation patterns have been described using observational data, qualitative methods may generate knowledge about contextual determinants of consultation behavior. Our objective was to understand how pediatric hospitalists make decisions about subspecialty consultation.
This qualitative study took place at a large academic children's hospital as part of an explanatory sequential mixed-methods design (QUAN → qual). We conducted semistructured interviews with a purposive sample of previously identified high-consulting (top quartile) and low-consulting (bottom quartile) pediatric hospitalists. Interviews were conducted virtually, and audio recordings were transcribed. Two analysts coded transcripts using an integrated approach and established high interrater reliability (κ > 0.75). We organized findings using the Social Ecological Model.
Participants (n = 12) included high-(n = 6) and low-(n = 6) consulting hospitalists. Our respondents identified considerations including patient characteristics, confidence in their own competence and that of their team, and perceived helpfulness of consultants. Participants viewed consultation requests as being strongly influenced by a desire to maintain relationships with families. Specific to this context, the hospital's elite reputation was believed to influence families to expect consultations. Other considerations included medicolegal risk, clinical pathways, and availability of secure text messaging to facilitate informal "curbside" conversations with subspecialists.
Decision-making around pediatric subspecialty consultation is complex and influenced by factors unrelated to a patient's clinical need. Efforts to reduce low-value consultation must account for the social and organizational dynamics that promote consultation.
住院患者专科会诊通常具有医学必要性，但在某些情况下也可能存在过度使用的情况。虽然已经使用观察性数据描述了儿科会诊模式，但定性方法可能会产生有关会诊行为的背景决定因素的知识。我们的目的是了解儿科住院医师如何做出专科会诊的决策。
本定性研究是在一家大型学术儿童医院进行的，作为解释性顺序混合方法设计（QUAN→qual）的一部分。我们对先前确定的高会诊（前四分之一）和低会诊（后四分之一）儿科住院医师进行了半结构式访谈。访谈是通过虚拟方式进行的，并对音频记录进行了转录。两名分析师使用综合方法对转录本进行编码，并建立了较高的评分者间一致性（κ>0.75）。我们使用社会生态模型组织研究结果。
参与者（n=12）包括高会诊（n=6）和低会诊（n=6）的住院医师。我们的受访者确定了一些考虑因素，包括患者特征、对自己和团队能力的信心以及顾问的帮助程度。参与者认为会诊请求受到与患者家庭保持关系的强烈影响。具体而言，医院的精英声誉被认为会影响家庭期望接受会诊。其他考虑因素包括医疗法律风险、临床路径以及使用安全的短信服务，以促进与专科医生进行非正式的“路边”对话。
儿科专科会诊决策是复杂的，受到与患者临床需求无关的因素的影响。为减少低价值会诊而进行的努力必须考虑到促进会诊的社会和组织动态。
