J Chron Dis Vol 36. No 3. pp. 213 to 218. 19X3 Prmted
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DEVELOPING STRATEGIES FOR IMPROVING THE DIAGNOSTIC AND MANAGEMENT EFFICACY OF MEDICAL CONSULTATIONS” RALPH Department
I. HORWITZ,
of Medicine.
Section
C. GREGORY
HENES
and SARAH
M.
of General Internal Medicme. Yale University New Haven. CT 06510, U.S.A.
HORWITZ School
of Medicine.
Abstract-To determine the clinical effects of internists’ consultations to surgeons and other non-internists. we studied a random sample of 250 consultations provided by the Yale Medical Service to patients admitted on non-medical services during 1978-1979. We found that consultations changed or confirmed a diagnosis in 82% (205). and changed or confirmed a management plan in 69”; (172). We also found that the diagnostic or management effects could be enhanced by several features of the way the consultation is performed: rapid response to the request for consultation: frequent follow-up notes by the consulting medical team; and detailed specifications of dosage and duration in recommendations for pharmacologic therapy.
INTRODUCTION
plays an increasingly important role in internal medicine today, occupying about one-fifth of all internists’ encounters and even larger proportions of work by medical subspecialists [l]. In academic training centers, faculty physicians often perform consultations directly by providing clinical care, or indirectly by supervising in-patient consultations carried out by residents and fellows [a]. Despite the importance of medical consultations, they have received relatively little research and most of what has been published has emphasized out-patient consultations among physicians in the community [3,4]. In the few studies of in-patient work, Perlman et ul. I.51 examined medical consulting by internists for 75 patients referred to the pulmonary service of a large county hospital, and Rudd et al. [6] evaluated 17 perioperative consultations requested for the management of patients with diabetes mellitus. The purpose of the current study was to describe the patterns of consultation provided by internists to surgical specialties, to consider consultations provided by all of the specialty services in a department of medicine, and to analyze both the recommendations and effects of the consultative process. CONSULTATION
RESEARCH
METHODS
We identified a sampling frame, between October 1 1978 and September 30 1979, of consultations performed by University faculty in the Department of Internal Medicine to the non-medical services at Yale-New Haven Hospital. These non-medical services included the following departments: General Surgery; diverse surgical specialties (Cardiovascular and Thoracic, Neurosurgery, Obstetrics and Gynecology, Opthalmology, Orthopedics, Otolaryngology, Plastic Surgery, Urology); Dermatology; Neurology; Pediatric Medicine; Psychiatry; and Radiation Medicine. Consultations were requested either by telephone or by sending a consultation-referral form to the office of the consulting *Dr Horwitz is a Henry .I. Kaiser Family Foundation Faculty Scholar in General Internal Medicine. Reprint requests should be addressed to Ralph 1. Horwitz. M.D.. Yale University School of Medicine, Cedar Street. P.O. Box 3333. New Haven, CT 06510. U.S.A. 213
333
214
T,uxf-
I. CONSLI.TATIONS IN STIIDY GKOL’I’ A<'COKDIVG TO MtDICAI. SL'RSI'ICIALTY (IV = 250) Consultmg
service
Study group
Cardiology Gastroenterology%w Infectious disease Renal/endocrine Hematology/oncology Pulmonary General medicine Rheumatology;immunology
80 (32”,,) 34(14”,,) 32 ( 13”,,) 29(12”,,) 27 ( lo’l,,) 22 (9’?,,) 18(7”J 8 (4”J
medical service. From the department billing records, or log books maintained by each medical specialty section (which did not include informal teaching consultations). we identified 1381 such consultations. We used the following method to select a random sample of 250 consultations. First. for each consulting service we calculated the number of consultations to be included using the formula C x S/N, where C represents the total number of consultations by a subspecialty medical service; S equals the desired number of consultations in the sample (250); and N equals the total number of consultations (1381). The list of patient consultations for each service was numbered consecutively. and the predetermined number of consultations was selected using a table of random numbers (Documenta Geigy Scientific Tables). The charts of psychiatric patients were not available to us. and consultations on these patients were excluded from the study. The distribution of these 250 consultations is shown in Table 1. Most of the 250 consultations were requested by surgical services. General surgery requested, 22%; surgical subspecialties. 54%; neurology. 8:~; dermatology, 7”;;; and obstetrics and gynecology, So/,. The remaining (496) requests came from other clinical specialties, such as Radiation Therapy or Pediatrics. Information describing the patients’ clinical conditions was excerpted from the hospital medical records by one of us (CGH) and entered into specially designed data forms. The diagnostic and management decisions of the requesting service were determined from information in the hospital medical record, and was supplemented by any additional information noted on the consultation-referral form. For the purpose of analysis, we defined three types of possible “effect” for each consultation. In our analysis, we chose to classify diagnostic and management confirmation as an important effect of the consultation. In many circumstances in which the clinical service is uncertain of a patient’s diagnosis or management, the consultation may contribute substantially to the care of the patient by confirming already existing clinical suspicions. For instance, a mycordial infarction may have been suspected in a heavily sedated post-operative patient in whom electrocardiographic abnormalities had developed. By appropriately performing cardiac isoenzymes or radionuclide studies. consultants were able to confirm the diagnosis of a recent myocardial infarction, and to initiate suitable therapy. A diaynostic effkt occurred if the consultation changed a diagnosis already made by the requesting service, or if the consultation confirmed an already suspected diagnosis. A managenzent c$fkct occurred if the consultant changed or initiated a set of management plans, or confirmed already specified plans. An implementation occurred if any of the consultant’s management recommendations were followed by the requesting service. To test certain results for statistical significance we used the chi-square test, uncorrected for continuity. To quantify the trend noted in an ordered sequence of rates. we used the chi-square procedure adapted for the analysis of linear trend [7]. RESULTS
OF
STUDY
Patients in the study had a mean age of 54 yr (with a standard deviation of + 19 yr). and 584;, were men. Of the 2.50 consultations, 427; were requested to evaluate an already
Developing
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TARLF 2. EFFECT OF CONSULTATIONS ON DIAGNOSIS AND MANAGEMENT(.w = 250)
Effect
Diagnosis
Changed Confirmed None Evident Total
100 105 45 250
Effect on Management
(40%) (42%) (18:,,) ( I OO:,;,)
122 50 78 250
(49%) (2OY,) (31”,) (100%)
established problem, and 58% to evaluate a medical problem first discovered during the current hospitalization. Diagnostic help was specifically requested in 51% of the consultations, and assistance in patient management in 61%. Diverse diagnostic and management recommendations emerged from the 250 consultations. Of the 365 diagnostic recommendations, blood tests accounted for 128; roentgenographic studies for 82; body fluid examinations, such as thoracentesis, for 65; endoscopy or biopsy for 33; specialized clinical examinations (such as neurological or opthalmological examination) for 29; and physiologic function assessments, such as pulmonary function tests, for 28. The 367 management recommendations included 245 for drug therapy; 63 for preparation for planned or suggested surgery; 17 for blood transfusions; and 11 for respiratory therapy. Table 2 shows the effect of the consultations on diagnosis and management. The consultations changed or confirmed a diagnosis in 82%, but in 18% no diagnostic effect was evident. Consultations without a diagnostic effect included those in which the consulting service did not alter or confirm the requesting service’s previous diagnostic suspicion. In these circumstances, the consulting service was sometimes able to exclude (or rule out) certain additional diagnoses not previously considered by the requesting service. For example, while evaluating a 62-yr old man with a post-operative fever, the consulting service considered and excluded certain disorders, such as pulmonary embolism, not considered by the requesting service. Nevertheless, despite a thorough clinical and laboratory investigation, the consulting service was unable to arrive at a specific diagnosis. Table 2 also shows that consultations changed or confirmed a management plan in 694;,. with no effect evident in 31%. The large group of consultations without an effect included many in which no clinical management recommendations were offered by the consulting service. To try to account for the large proportion of consultations without diagnostic or management effect, we examined several features of the way the consultation was performed by the clinical services. Table 3 shows the relationship between the length of the consultation interval and the diagnostic and management effect. The consultation interval was defined as the time between the date the consultation is received by the consulting service and the date the first consultation note is recorded in the medical chart. Consultations are divided into those with a long interval, greater than 1 day (80 consultations), and those with a short interval, less than or equal to 1 day (170 consultations). Compared with long interval consultations. those with a short interval had a significantly increased diagnostic (x2 = 5.4; p < 0.05) or management effect (x2 = 38.0; p < 0.001).
TABLE 3. R~LATIOKSHIP OF CONSULTATION INTEKVAL TO DIAGNOSTIC AND MANAGtM~NT WFECT
Consultation Interval
No. of consultations
Long Short 1’ (diagnostic) I, < 0.001.
80 170 = 5.4;
p < 0.05;
Diagnostic effect 74”,, (59) 869,, ( 146) ,yz
Management effect 42’:” (34) 81”,, (13X)
(management)
= 38.0;
216
RALPH I. HORWTZ
cr trl
TAHLE 4. RI LATIONSHIP OF (‘OKSCLTATIOU YOTt,S TO DIAC;iXOSTICAND MANAGFMFNT EFFECT No. of notes
No. of consultations
FCW Many
137 113
Diagnostic effect
Management effect 56”/, (77) g4:,, (95)
74”;) (101) 92”,, (104)
x2 (diagnostic) = 14.1: p < 0.001 : xz (management) 22.4, p < 0.001.
=
TARLF 5. SPECIFYING DOSAGt AND/OR DURATION 0,. DRI'G THFRAPY AND IMpLEMtUTATION OF MANAGEMrNT RECOMMENDATION
Specified: Dose & duration Dose or duration (not both) Neither
Implementation Yes No
0
Total
32 (loo”,,) 163 (X5”,,)
2X
32 I91
I4 (64”,,)
8
22
x;, = 12.65: p < 0.001.
In Table 4. we examined whether writing frequent follow-up notes increased the diagnostic or management effect of the consultation. For analysis, we divided consultations into those with few notes (an original note with no more than 1 follow-up note), and those with many notes (2 or more follow-up notes). Among the 137 consultations with few notes. diagnostic effect occurred in 74”,/o and management effect in 56”/,,. A significant increase in diagnostic (x2 = 14.1; p < 0.001) or management effect (i(’ = 22.4; p < 0.001) occurred among the 113 consultations with many notes. As shown in Table 5, the consultant’s specification of both dosage and duration for drug therapy greatly improved the likelihood that the management recommendations would be implemented. The implementation rate was 100% when both dose and duration of drug therapy were specified; 8.5% when dose or duration, but not both were specified; and only 64”:, when neither dose nor duration was specified. The gradient of increased implementation for increasing specificity of the therapeutic recommendation showed a highly significant linear trend (xt = 12.6; p < 0.001). Another important yet often overlooked benefit of medical consultations is the discovery of unsuspected but clinically important medical problems. To be counted in our analysis, an unsuspected clinical problem needed to fulfill two criteria: (1) that the consulting physician identified the problem during his initial assessment of the patient; and (2) that the problem required therapeutic intervention during the current hospitalization. In the total group of 250 consultations, unsuspected problems were discovered in 21%. The discovery rate varied widely among the consulting services, and ranged from 56”/;1in 18 general medicine consultations to 29,, in the 14 consultations by the Oncology Service. The number of unsuspected problems discovered by each service is listed in
TABLI 6. DISCWVFRY OF L'USLJSPFCT~DPROHLEMS BY CONSIJLTINC SIRVICT
Consulting service General medicine Rheumatology/immunology Hematology/oncology Renal:endocrine Infectious disease Pulmonary Gastroenterology.‘liver Cardiology
No. of consultations 18
x 27 29 32 22 34 X0
“() (and No.) of unsuspected problems 56”,,(lO) 25”,, (2) 22”,, (6) 21”,, (6) l9”,, (6) l9”,, (4)
18”,,(6) l5”,,(12)
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217
Table 6. The General Medicine Service, compared to the other clinical services, discovered a larger proportion of patients with unsuspected medical problems. However, we have not attempted to draw any further inferences from the data in this table, since individual consulting services saw patients of widely differing complexity.
DISCUSSION
This study provides quantitative evidence that consultations by internists to surgical and other non-medical services frequently provide important diagnostic and management information. Diagnostic effects occurred in 82% of the consultations, and management effects in 69%. Furthermore, the diagnostic or management effects could be enhanced by several features of the way the consultation is performed: rapid response to the request for consultation; frequent follow-up notes by the consulting medical team; and detailed specifications of dosage and duration in recommendations for pharmacologic therapy. Some of these phenomena have been previously noted. In a study of medical consultation to 75 patients referred to the Pulmonary Service of a county hospital, Perlman rt al. [IS] concluded that inadequate patient follow-up contributed to the high proportion of consultations without a therapeutic effect. In a study of 17 peri-operative consultations requested for the management of diabetes mellitus. Rudd et al. [6] suggested that the consultant “should make explicit management recommendations in his note”. The investigators stated that vague statements such as “avoid overly tight diabetic control” were usually associated with poor therapeutic effect because the requesting service was unable to implement specific actions. Our study provides quantitative evidence to support this point. When drug recommendations include detailed descriptions of therapeutic management (e.g. “40 units of NPH insulin, subcutaneously each morning for 3 days”), implementation in our study was 100%. An alternative explanation for our findings is that diagnostic and management effects occur more often in seriously ill patients for whom consultations are performed promptly and with frequent follow-up. We did not collect the data necessary to classify accurately each patient’s illness severity. However, the study results were not altered by analyses using characteristics that are surrogates for illness severity: the number of serious comorbid diseases and the length of hospital stay. An additional finding in our study was the consultant’s frequent discovery of unsuspected but clinically important medical problems. In particular, general internists were especially likely to discover and treat these problems. Rudd rt al. [6] had also noted that the consultant, while confirming the requesting service’s general impressions about the management of the patient’s diabetes mellitus, often added at least one more major medical diagnosis. The quantitative analysis performed in this study cannot fully reflect the importance an individual consultation may have had on a patient’s clinical care. The case reports that follow provide examples of the therapeutic contribution of medical consultations. The general Surgery Servxe asked the Hematology Service for diagnostic help in determining the cause of persistent post-operative leukopenia In a 76-yr old woman with painless jaundice who had undergone choledochojejunostomy for a pancreatic tumor. In addition to detecting previously unrecognized splenomegaly as the cause for the Ieukopenia. the hematologist also diagnosed adult respiratory distress syndrome, which led to spccitic thcrap! for a life-threatening post-operative complication.
By correcting errors in diagnosis. consultants in this study often helped to manage difficult therapeutic problems. An example is shown in the following case report: The Dermatology Service requested the Infectious Disease division to propose antibiotic therapy of a suspected septic joint in a 70.yr old man hospitalized for treatment of pemphigus foliaceus. While receiving high dose systemic corticosteroids. the patient’s temperature rose to 101-F. and cellulitis was noted over the left elbow The consulting physician confirmed the diagnosis of cellulitis, but excluded the presence of any concomitant JoIn involvement. Therapy with intravenous oxacillin was initiated as recommended, and the consultant wrote daily notes to direct therapy. Even though the original request was for asslsrance in managing a septic joint. the consultant first corrected a mistaken diagnosis,
21x
RALPH
I. HORW
rz U( Q/.
Since physicians requesting a consultation may not accurately or precisely specify the clinical problem. consultants who focus only on the text of the clinical request may overlook important clinical phenomena. A solicitation of diagnostic assistance almost always requires therapeutic advice; management request can rarely be answered without first validating the accuracy of the clinical diagnosis; and regardless of the apparent problem that stimulates the consultation, the physician should be alert to other serious and unrecognized medical problems. Although the vital role of consultative medicine in the health care system has been established 121, only a few investigations have attempted to identify the characteristics of a consultation that determine its diagnostic and management effects. Our study. which illustrates the importance of prompt response and careful patient follow-up. should help to guide both the physician performing a consultation and the program director responsible for training the resident or fellow to be an effective consultant. In further studies, investigators should look beyond the consultative process to examine the impact on patient outcomes. REFERENCES Mendenhall RC. Tarlov AR, Girard RA, Michel JK. Radeckl SE: A national study of internal medicine Ann Int Med 9 I : 275 287. 1979 and its specialties. II. Primal .y care in internal medune. Tarlov AR. Weil PA. Schlecter MK, the Association of Professors of Medicine Task Force on Manpower: A national study of internal medicine manpower. III. Subspecialty fellowship training l976-- 1977. Ann Int Med 91: 295 300, 1979 Brock C: Consultation and referral patterns of family phystcians. J Family Pratt 4: II29 I 134. 1977 Saunder TC: Consultation referral among physicians: practice and process. J Famil Pratt 6: 123 128. 1978 Perlman LV. Kruskall MS. Rosenzweig D. Kaufman J: Process and outcome in medical consultations: evaluation on a pulmonary service. Postgrad Med 57: I 1 I 1 15, 1975 Rudd P. Siegler M. Byyny RL: Perloperative diabetic consultation: a plea for improved training. J Med Educ 53: 590 596. 1978 Feinstein AR. Clinical Biostatistics, Chapter 28. St LOUIS: C. V. Mosby, 1977