Clinical and Financial Implications of Consulting Physicians in the Management of Surgical Patients

Abstract

Background

The present study was designed to evaluate the immediate consequences that the number of consulting physicians has on length of stay (LOS), in-hospital mortality, 30-day readmission rates, direct health care costs, and contribution margins.

Methods

A retrospective review of administrative databases for the years 2013 and 2014 was performed at the Florida Hospital Adventist Healthcare System.

Results

11 274 patients were included in the analysis. Total and variable costs increased by $1347 and $592, respectively, with each consulting physician service per patient. The contribution margin decreased by $354 per patient/consulting physician. Each consulting physician increased LOS by .72 days and increased odds ratio of mortality and 30-day readmission by 5% and 3%, respectively.

Conclusions

Our research suggests that each consulting physician added to the care of an individual surgical patient negatively affected LOS, readmission rates, in-hospital mortality, and costs.

Keywords

consult hospitalist cost

Introduction

Co-management, in which multiple consulting physicians participate in the care of hospitalized patients, is gaining popularity as more patients present with an increasing number of complex comorbidities. Multiple reports published over the last several years have addressed the role of dedicated hospitalist services that share responsibilities in the management of patients admitted to a variety of surgical specialists including vascular,¹ neurosurgery,² orthopedics,³ and pediatric surgery.⁴ In general, hospitalist services comprise internists who focus their practice on inpatient management. Hospitalists usually address basic care needs and rely on consultation of specialists for more specific necessities.⁵

According to the Society of Hospital Medicine and the American Hospital Association,⁶ an estimated 30 000 hospitalists are currently practicing in nearly one-third of hospitals throughout the United States.⁷ Although likely multifactorial in nature, increasing numbers of frail elderly patients requiring longer hospitalizations, reimbursement constraints, and current resident work-hour limitations have contributed to the proliferation of these dedicated hospitalist services^8,9 both in community and in academic institutions.

Despite the growing phenomenon in which the admitting surgeon relies on an alternative physician for a significant portion of the patient’s care, the available data are unclear as to whether this approach improves perioperative care and expedites discharge of patients postoperatively. Some studies have shown that involvement of a hospitalist may have favorable effects on in-hospital mortality rates, patient safety, and pain scores,¹ while others have found no differences in readmission rates or length of stay (LOS).¹⁰ Some authors have proposed that having a hospitalist service available improves surgeon satisfaction, resource utilization, timeliness of patient care, communication among referring physicians, and house staff supervision.¹¹ Nonetheless, reports addressing the financial implications of a dedicated hospitalist service have shown mixed results.¹² Finally, the patient’s perception of having several providers managing their care has also been questioned.^13,14

To date, the implications of having multiple physicians caring for the same surgical patient have not been evaluated in detail. Thus, the purpose of this study was to examine the consequences that consulting physicians have on patients admitted to surgical services. We focused our research in determining specifically the relationship between the number of consulting physicians involved in patient care and both clinical and financial outcomes including LOS, in-hospital mortality, 30-day readmission rates, costs, and contribution margins.

Methods

After obtaining approval from the AdventHealth Orlando Institutional Review Board, we retrospectively reviewed financial and clinical outcomes of surgical patients available from prospectively maintained administrative databases. Consecutive patients admitted to the Adventist Healthcare System in the Central Florida region for the years 2013 and 2014 were included in the analysis.

Admitting Institution

The Adventist Healthcare system is a not-for-profit health care system with 22 campuses throughout the state of Florida. Seven of these campuses are in the Central Florida region with a hybrid tertiary referral center that shares both traditional community and academic characteristics. The main campus is a 2247-bed acute care medical facility, with 2230 staff physicians where more than 122 729 inpatient admissions occur annually. Approximately 64 552 outpatient and inpatient surgeries are performed yearly.

Study Population

Patients included in the final investigation underwent both elective and emergent operations. Surgeries were identified by principal procedure codes from the International Classification of Diseases, 9th Revision, and Clinical Modification (ICD-9-CM). Patients ≥18 years old with an inpatient status of ≥1 hospital day were analyzed. Table 1 demonstrates the type and frequencies of surgeries performed during the study period. Age, gender, admission type (elective or emergent), admission source (non-health facility, clinical referral, another facility, skilled nursing facility, and acute hospital), insurance payer (managed care, Medicaid, Medicare, Government and Workman’s Comp, and self-pay), ICD-9 procedure and diagnosis codes, All Patient Refined Diagnosis Related Group (APR-DRG) risk of mortality and severity of illness, and Medicare Severity-Diagnosis Related Group relative weight were collected for each study patient.

Table 1.

Types and Frequency of Procedures Included.

ICD-9 Principle procedure code	ICD-9 code description	Number of cases
51.23	Laparoscopic cholecystectomy	3755
47.01	Laparoscopic appendectomy	1633
44.38	Laparoscopic gastroenterostomy	455
43.82	Laparoscopic vertical gastrectomy	366
17.33	Laparoscopic right hemicolectomy	287
45.76	Open sigmoidectomy	244
45.73	Open right hemicolectomy	244
97.02	Replacement gastrostomy tube	217
51.22	Cholecystectomy	216
17.36	Laparoscopic sigmoidectomy	171
46.51	Closure of stoma of small intestine	171
53.62	Laparoscopic incisional hernia repair with graft or prosthesis	146
46.52	Closure of stoma of large intestine	144
53.69	Other and open repair of other hernia of anterior abdominal wall with graft or prosthesis	139
48.81	Incision of perirectal tissue	128
47.09	Other appendectomy	118
54.00	Incision of abdominal wall	116
53.51	Incisional hernia repair	110
83.09	Other incision of soft tissue	90
54.21	Laparoscopy	88
52.7	Radical pancreaticoduodenectomy	85
45.75	Open left hemicolectomy	84
53.63	Other laparoscopic repair of other hernia of anterior abdominal wall with graft or prosthesis	83
44.39	Other gastroenterostomy	80
41.5	Total splenectomy	66
46.10	Colostomy	61
53.59	Repair of other hernia of anterior abdominal wall	60
49.01	Incision perianal abscess	57
43.19	Gastrostomy	54
52.52	Distal pancreatectomy	53
54.24	Closed [percutaneous] [needle] biopsy of intra-abdominal mass	52
17.35	Laparoscopic left hemicolectomy	50
97.51	Removal gastrostomy tube	49
50.22	Partial hepatectomy	49
44.42	Suture duodenal ulcer site	47
85.21	Local excision breast lesion	47
48.69	Rectal resection nec	46
44.97	Laparoscopic removal of gastric restrictive device	44
50.30	Lobectomy of liver	44
97.03	Replacement of tube or enterostomy device of small intestine	43
83.14	Fasciotomy	38
45.81	Laparoscopic total intra-abdominal colectomy	37
45.82	Open total intra-abdominal colectomy	36
57.83	Repair of fistula involving bladder and intestine	36
53.49	Other open umbilical herniorrhaphy	36
46.42	Repair of pericolostomy hernia	35
07.22	Unilateral adrenalectomy	35
46.39	Duodenostomy/feeding enterostomy	32
51.01	Percutaneous aspiration of gallbladder	32
54.19	Drainage of intraperitoneal abscess or hematoma	31
43.7	Partial gastrectomy with anastomosis to jejunum	30
46.74	Closure of fistula of small intestine, except duodenum	30
83.21	Biopsy of soft tissue	29
54.95	Incision of peritoneum	29
48.51	Laparoscopic abdominoperineal resection of the rectum	29
31.29	Other permanent tracheostomy	29
42.7	Esophagomyotomy	28
45.72	Open and other cecectomy	28
44.41	Suture of gastric ulcer site	27
85.12	Open biopsy of breast	26
48.62	Anterior resection of rectum with synchronous colostomy	26
17.32	Laparoscopic cecectomy	25
54.12	Reopening of recent laparotomy site	25
52.6	Total pancreatectomy	24
43.99	Other total gastrectomy	24
86.09	Other incision of skin and subcutaneous tissue	24
17.34	Laparoscopic resection of transverse colon	23
45.14	Closed [endoscopic] biopsy of small intestine	23
85.41	Unilateral simple mastectomy	21
51.37	Anastomosis of hepatic duct to gastrointestinal tract	21
85.91	Aspiration of Breast	20
45.83	Other and unspecified total intra-abdominal colectomy	20
06.20	Unilateral thyroid lobectomy	19
43.89	Partial gastrectomy with bypass gastrogastrostomy	19
	Sleeve resection of stomach
50.14	Laparoscopic liver biopsy	19
45.93	Other small-to-large intestinal anastomosis	19
83.32	Excision of lesion of muscle	18
44.69	Inversion of gastric diverticulum	18
	Repair of stomach NOS
40.30	Regional lymph node excision	18
52.59	Other partial pancreatectomy	17
86.21	Excision pilonidal cyst	15
49.73	Closure of anal fistula	14
82.29	Excision of other lesion of soft tissue of hand	14
48.40	Pull-through resection of rectum, not otherwise specified	14
44.50	Revision of gastric anastomosis	13
46.43	Other revision of stoma of large intestine	13
46.75	Suture of laceration of large intestine	12
50.12	Open biopsy of liver	12
40.24	Excision of inguinal lymph node	12
44.63	Closure of other gastric fistula	12
06.81	Complete parathyroidectomy	12
45.91	Small-to-small intestinal anastomosis	12
53.90	Other hernia repair	11
50.29	Other destruction of lesion of liver	11
17.24	Laparoscopic bilateral repair of inguinal hernia with graft or prosthesis	11
49.11	Anal fistulotomy	10
45.02	Other incision of small intestine	10
47.11	Laparoscopic incidental appendectomy	9
52.96	Anastomosis of pancreas	9
Total		11 274

Abbreviation: ICD, international classification of diseases.

Consulting Physician

A consulting physician was defined as one that acted in an advisory capacity to the patient’s primary physician. The number of consulting physicians was matched to each study patient.

Financial Outcomes

This study’s hospital system uses commercially available financial software to categorize actual general ledger expenses as either variable or fixed costs. Total cost included fixed and variable costs and was defined as all variable and fixed hospital expenditures required to provide direct patient care and to operate the facility. Fixed costs were all expenditures that did not change with business volumes. Examples include management salaries, benefits as well as depreciation of equipment and buildings. Variable costs were defined as all expenditures that vary on the basis of changes in business volume including nursing and other direct patient care salaries, benefits, supplies, and drugs.

Each discharged patient was allocated a pro rata portion of the variable costs according to specific charges incurred. Contribution margin, an indicator of a hospital’s profitability, was defined as total actual payments minus variable costs as defined before.¹⁵ Total cost, variable cost, fixed cost, and contribution margin were matched to each study patient. Since our primary focus was the hospital financial impact that the number of consulting physicians had on each patient care episode, we used total cost, variable cost, and contribution margin as outcomes.

Clinical Variables

The clinical variables studied for this research included LOS, mortality, and 30-day readmission rates. Mortality rates reflect only those individuals that expired within our health care system during the index admission. Readmission rates were analyzed using the patient’s unique medical record number that remains constant throughout the patient’s readmission to satellite locations. If one admission occurred within 30 calendar days after the previous discharge, the previous hospital visit was flagged as the one that caused a 30-day readmission event.

Statistical Analysis

We analyzed relationships between the number of consulting physicians during the patient’s hospitalization and financial outcomes including total cost, variable cost, and contribution margin, as well as clinical outcomes including LOS, mortality, and 30-day readmission. Multivariate linear regression was used to estimate continuous outcome measures including costs, contribution margin, and LOS. Multivariate logistic models were used to estimate binary outcome measures including mortality and readmission rates. We included the following covariates in the models in order to adjust for potential confounding factors: DRG relative weight, age, gender, insurance payer, admission source, admission type, APR-DRG risk of mortality and severity of illness, and ICD-9 principal procedure codes. Discrete variables including insurance payer, admission source, admission type, and ICD-9 principal procedure codes were coded as categorical variables; gender was coded as a binary variable. For each coded variable, the value with the largest percentage was utilized as default, so it would not be included in the final models (defaults = female, managed care, non–health care facility admission source, ER admission type, and laparoscopic cholecystectomy ICD-9 principal procedure).

Model evaluation and refinements were also conducted. Multicollinearity was evaluated for each multivariate linear regression model using tolerance and variance inflation factor (VIF), which indicates the degree of multicollinearity of each independent variable with the other independent variables in the model. All independent variables have a VIF < 3, which are less than 10, the value or higher indicating higher multicollinearity. Outliers for total cost, variable cost, contribution margin, and LOS were also checked and excluded from the final models based on outlier identification technique. All tests and 95% confidence intervals (CI) were two-sided. P-values less than .05 were considered statistically significant. For regression analysis, we reported our results in terms of estimated parameters, associated P-values, and adjusted R² values from each model. For the logistic model, the results were reported in terms of estimated odds ratios, pseudo R², associated P-values, and c-statistics from each model. All statistical analyses were performed using Stata^® 13.1 software.

Results

Descriptive statistics and demographics of the entire studied population are shown in Table 2. A total of 11 274 patients underwent the previously detailed operations during the studied period. Patients with managed care insurance accounted for the highest percentage of patients (39%), followed by Medicare (32%), Medicaid (14%), self-pay (12%), and other insurances (3%). The total and variable costs per case (mean SD) were $15 368 ($23 815) and $6799 ($11 317), respectively, and the contribution margin per case was $8174 ($24 382).

Table 2.

Demographics.

Characteristics	Measurement
Year
2013	5615
2014	5659
Total	11 274
Patient specific demographics
Age: (mean ± SD)	51.4 ± 18.2 years
Gender %
Male	41.5%
Female	58.5%
Clinical outcomes
LOS (mean ± SD)	6.04 ± 9.54 days
Mortality rate %	.91%
Total number of in hospital deaths	103
30 day readmission rate %	11.55%
Total number of readmissions	1302
Number of consulting physicians (mean ± SD)	3.76 ± 3.94

Abbreviation: LOS, length of stay.

Table 3 depicts the estimated mean impact of one consulting physician on both financial and clinical outcome measures. This table shows that for each consulting physician service used per patient, total and variable costs increased by $1347 and $592, respectively. Meanwhile, the contribution margin decreased by $354 per patient/consulting physician. For clinical outcomes, one consulting physician service increased a patient’s LOS by .72 days and increased the odds ratio of mortality and 30-day readmission by 5% and 3%, respectively. All impacts on outcome measures were significant at <.05 level.

Table 3.

Summary of Adjusted Model Parameter Estimate Results

Outcome	Mean estimate per consulting physician	P value
Total cost, $ [95% CI]	$ 1347 [1301 to 1,393]	<.001
Variable cost, $ [95% CI]	$ 592 [571 to 613]	<.001
Contribution margin, $ [95% CI]	$−354 [−424 to −284]	<.001
Length of stay, days [95% CI]	.72 [.70 to .75]	<.001
Mortality, odds ratio [95% CI]	1.05 [1.00 to 1.11]	.048
30-day readmission, odds ratio [95% CI]	1.03 [1.00 to 1.05]	.021

Abbreviation: CI, confidence intervals.

Tables 4 and 5 show the detailed model results for the impact on outcomes by other independent variables. When compared to a managed care patient, a patient with other types of insurance did not have a statistically meaningful difference in total cost and variable cost (exception: Medicaid is slightly higher than managed care); however, contribution margin is significantly lower by over $10 000 per case. This reveals that managed care patients brought higher revenue to this hospital system than patients with other insurance. APR-DRG risk of mortality and severity of illness appear to be important risk adjusters and have significant impact on most of the outcome measures. DRG weight is a Center for Medicare and Medicaid Services resource utilization score and appears to have impact on costs and contribution margin but not the clinical outcomes.

Table 4.

Influence of Payer on Financial Outcome (Mean Estimates)

	Total cost	Variable cost	Contribution margin	P value
Medicaid	NS	NS	$−17 824	<.001
Medicare	NS	NS	$−17 824	<.001
Self-pay	NS	NS	$−23 031	<.001
Worker compensation /government	NS	NS	$−16 253	<.001

Table 5.

Adjusted Model Mean Estimates.

	Mean cost	P value
DRG weight
LOS	NS	NS
Total cost	$1,111	<.001
Variable cost	$523	<.001
Margin	$2,124	<.001
Mortality (OR)	NS	NS
30-day readmission (OR)	NS	NS
Severity of illness
LOS	.75	<.001
Total cost	$1135	<.001
Variable cost	$424	<.001
Margin	NS	NS
Mortality (OR)	2.21	.014
30-day readmission (OR)	1.24	<.001
Risk of mortality
LOS	.47	<.001
Total cost	$663	<.001
Variable cost	S307	<.0001
Margin	MS	NS
Mortality (OR)	6.9	<.001
30-day readmission (OR)	NS	NS
Adjusted R ² characteristic
LOS	.64	.64
Total cost	.64	.64
Variable cost	.63	.63
Margin	.55	.55
Mortality (OR)	NS	NS
30-day readmission (OR)	NS	NS
Pseudo R ² characteristic
LOS	NS	NS
Total cost	NS	NS
Variable cost	NS	NS
Margin	NS	NS
Mortality (OR)	.53	.97
30-day readmission	.09	.72

Abbreviations: OR, odds ratio; LOS, length of stay.

Discussion

The present study investigated the relationship between the number of consulting physicians involved in the care of surgical patients and its immediate implications on LOS, mortality, readmission rates, and health care costs. Surgical procedures that required hospitalization for at least one day were incorporated into our analysis. Surgeries examined were interventions frequently performed at both community and academic settings by general surgeons, although other complex surgical procedures such as pancreatic and hepatic resections were also analyzed. Financial variables assessed combined both fixed and variable costs as well as contribution margins per attending consultant. Our research showed that each consulting physician added to the care of an individual surgical patient negatively affected LOS, readmission rates, and in-hospital mortality. Health care costs were also increased with the mounting number of consultants with an average decline in contribution margins of $354 per patient/consultant, although this was more evident with self-paying patients. Even though our study was not designed to evaluate the usefulness and cost-effectiveness of dedicated hospitalist services, adding any type of consultant to the care of patients regardless of the specialty had negative implications on both clinical and financial variables in the present study.

Despite interhospital and geographical disparities in the use of hospitalist services¹⁶ and health care resources¹⁷ in the United States, over the last several years, the participation of general medicine practitioners in the management of surgical patients has risen exponentially.^18,19 In one of the largest retrospective studies looking at the impact of co-management services on Medicare patients, Sharma demonstrated an 11% increase per year in the number of generalists involved in the care of surgical patients.²⁰ Elderly comorbid patients and those receiving care at midsize nonteaching institutions were more likely to have hospitalists involved in their care. General and orthopedic surgical services had the highest number of patients involved with co-management services, although analysis of the dataset was restricted to only 15 of the most common procedures performed on Medicare patients. Despite the lack of outcome data in this study, the authors advocated for training more general practitioners to satisfy the growing demand of hospitalist in the management of surgical patients. In this regard, studies have emphasized the need for curricular changes²¹ and training of general medicine practitioners which incorporates conditions and procedures commonly needed in surgical patients.²²

Attributing improvements in clinical results by the addition of dedicated hospitalist services is a challenging task, as the majority of prior retrospective studies have not controlled for other variables affecting outcomes.²³ There are a few quasi-randomized controlled studies that have attempted to answer the question of whether these services truly improve postoperative care and if they are cost effective.^3,24-26 Huddleston randomized 526 postoperative orthopedic patients who were at an elevated risk for perioperative complications to a team of a hospitalist plus an orthopedic surgeon or a team composed of an orthopedic surgeon and residents with an internist consulting on an as-needed basis. In this study, minor complications were lower in the hospitalist group, and LOS, after adjusting for discharge delays, was half a day shorter in the hospitalist-based team. Hospital and total costs were similar between groups, but the hospitalist group had higher physician-related expenses.

It is unclear from the available data how the addition of a hospitalist service impacts direct care costs. Some authors have shown benefit and significant reductions in total care costs with the addition of hospitalist services,^27-29 but this have not been uniformly reported throughout the literature.³⁰ Theoretical financial advantages of having co-management services include decreasing postoperative complications rates, decreasing LOSs, and allowing surgeons to increase productivity by spending more time in the operating room.⁴ A clear limitation that the majority of published studies have is that most authors have failed to differentiate costs associated with professional services provided by hospitalists vs. costs from additional resources utilized by hospitalists, making it difficult to truly estimate the added financial benefits of co-management services. Evidence-based rationalization of unnecessary testing and medications has the potential to improve some of the economic variables associated with the use of co-management services.^31-33

Studies conducted addressing the role of dedicated hospitalist services have not specifically focused on the number of consultants involved in the care of patients. Although unique in such aspect, our study is limited by several factors inherent to the analyses of large retrospective databases. It is not clear from our research how many times a particular consultant was involved in the care of a particular patient nor how this affected the cost and clinical results. It is also difficult to establish if some of the clinical outcomes (for instance, LOS) were biased by uncontrollable elements such as bed availability at rehabilitation centers, social support at the time of discharge, and attending preference. Additionally, patients readmitted following discharge from our system to an alternative institution were not tracked in this study, and therefore, accuracy of readmission rates was dependent on whether the patient was included on the database used. Despite these unavoidable restrictions, the large number of patients analyzed and the wide spectrum of surgical interventions included here strengthen our findings.

In conclusion, this study has shown negative clinical and financial outcomes when multiple consulting physicians are involved in the care of surgical patients. Until dependable research becomes available, a surgeon should consider relinquishing the management of surgical patients to nonsurgical physicians under only exceptional circumstances.³⁴

Footnotes

Acknowledgment

The authors would like to thank Cathy Stankiewicz, R.N., Director of Clinical Quality at AdventHealth for her support with this research.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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