Interdependence in decision-making by medical consultants: implications for improving the efficiency of inpatient physician services

ABSTRACT

Objectives: 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.

Methods: 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.

Results: 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.

Conclusion: 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.

KEYWORDS:

• Consultations
• physician decision-making
• efficiency
• postoperative
• patient care management

Declaration of interest

The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

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Additional information

Funding

This work was supported by the Blue Cross Blue Shield of Michigan Foundation (2059.II), the National Institute on Aging (Grant No. P01AG019783), the Agency for Healthcare Research and Quality (Career Development Grant Award K08HS020671), and the University of Michigan MCubed program.