Subspecialty Consultation Patterns in Pediatric Hospital Medicine

By Andrew Kern-Goldberger, MD, MSCE

As pediatric hospital medicine (PHM) specialists, my colleagues and I direct the care of hospitalized patients with a broad range of acute and chronic conditions. On a daily basis, one of the most impactful decisions we make is whether to consult other subspecialists to advise on the care of our patients.

Considerations for inpatient consultation

In many cases, consultation links patients to critical expertise that guides diagnosis and management, and underuse of this practice can deprive patients of access to this expertise. In contrast, when used inappropriately or excessively, consultation can lead to increased resource utilization, miscommunication, and patient and family dissatisfaction.¹ Despite the highly consequential nature of this practice, while inpatient consultation practices are well-described in the adult literature, consultation practices for hospitalized children have historically been poorly characterized.

Taking a scientific approach

Recognizing the paucity of pediatric literature on this topic, while a PHM fellow at Children’s Hospital of Philadelphia, my colleagues and I developed a research agenda to advance our understanding of pediatric inpatient consultation and, ultimately, design systems to optimize its use.² The first step was to characterize the factors associated with variability in inpatient subspecialty consultation among pediatric hospitalists, hypothesizing that physician anxiety due to uncertainty would be associated with increased consultation use.

In this study,³ we surveyed 92 active hospitalists, inquiring about their demographics, clinical experience, and a validated tool measuring physician anxiety due to uncertainty. We then merged our survey results with a dataset derived from the electronic health record containing the clinical information for patients cared for by the aforementioned hospitalists across 15 common inpatient general pediatric conditions between October 1, 2015, and December 31, 2020. We evaluated which patient-, physician-, and systems-level factors were associated with ³1 consultation on a given patient-day and described variation in consultation use across pediatric hospitalists.

Insurance and physician experience linked to consultation use

Contrary to our hypothesis, we found that physician anxiety due to uncertainty was not associated with consultation use. Rather, after adjustment for confounding factors, we found that odds of consultation were higher among patients with private insurance (compared to Medicaid) and among physicians with less attending experience (0-2 years vs. 3-10 years).

Findings raise questions about racial equity and access

Importantly, in a subanalysis of patient-days with³ 1 consultation, we found that non-Hispanic white children had over twice the odds of receiving multiple consultations compared to non-Hispanic Black children, suggesting racial differences in consultation intensity when hospitalists seek subspecialty involvement.

Furthermore, after accounting for the unique distributions of patients cared for by each physician, adjusted physician consultation rates were 2.1 times higher in the top quartile of consultation use compared with the bottom quartile. As described in an accompanying editorial by an expert in consultation practices for adult patients,⁴ these findings indicate significant variability in consultation simply based on the hospitalist to which a patient is assigned; and raise important questions about equitable access to subspecialty care.

The decision to consult is multifactorial

To gain further context for our findings, in a follow-up study we interviewed a subset of hospitalists to determine drivers of consultation not elucidated in the quantitative data.⁵ Among other factors, we found that decisions to request consultation were strongly influenced by additional characteristics, including the desire to meet family expectations of subspecialty involvement, confidence in hospitalists’ own confidence and that of trainees on the team, medicolegal considerations, and perceived helpfulness of subspecialty consultants.

These findings reinforce the multifactorial nature of decision-making around subspecialty consultation, including factors beyond medical necessity, and demonstrate the need to account for social and organizational dynamics in efforts to improve the high-value use of consultation.

In practice: Standardizing consultation use

Current and future directions for this work include understanding the patient-level outcomes of subspecialty consultation use for common pediatric inpatient conditions; assessing barriers and facilitators to standardizing consultation use at Cleveland Clinic Children’s and other Pediatric Research in Inpatient Settings Network hospitals; and developing and evaluating outcomes of clinical decision support interventions to standardize consultation use.

My research interest in subspecialty referrals extends to the outpatient setting, in which novel, evidence-based mechanisms of consultation, including asynchronous electronic consultation (eConsults) have recently emerged, and further study is required to understand barriers to their implementation in the pediatric population.⁶

References

1.Ng IKS, Lim SL, Teo KSH, Goh WGW, Thong C, Lee J. Referring wisely: knowing when and how to make subspecialty consultations in hospital medicine. Postgrad Med J. Aug 29 2024;

2.Kern-Goldberger AS, Money NM, Gerber JS, Bonafide CP. Inpatient Subspecialty Consultations: A New Target for High-Value Pediatric Hospital Care? Hosp Pediatr. Nov 3 2021;

3.Kern-Goldberger AS, Dalton EM, Rasooly IR, et al. Factors Associated With Inpatient Subspecialty Consultation Patterns Among Pediatric Hospitalists. JAMA Netw Open. Mar 1 2023;6(3):e232648.

4.Stevens JP. Specialty Consultation Use by Pediatric Hospitalists-A New Type of Health Care Variation. JAMA Netw Open. Mar 1 2023;6(3):e232655.

5.Kern-Goldberger AS, Bracy D, Szymczak JE, et al. Drivers of Inpatient Subspecialty Consultation Among Pediatric Hospitalists: A Qualitative Study. Hospital Pediatrics. 2024;14(9):782-789.

6.Ray KN, Wittman SR, Mehrotra A. Moving eConsults Into Mainstream Pediatric Care. JAMA Pediatr. Jul 1 2024;178(7):647-648.

About the author: Dr. Kern-Goldberger is staff physician in the Division of Pediatric Hospital Medicine, Assistant Professor of Pediatrics at Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, and investigator in Cleveland Clinic’s Center for Value-Based Care Research and Lerner Research Institute Department of Quantitative Health Sciences.