Sarah A. Stella, MD

METHODS

RESULTS

DISCUSSION

METHODS

RESULTS

DISCUSSION

METHODS

RESULTS

DISCUSSION

The period immediately following hospital discharge is particularly hazardous for patients.[1, 2, 3, 4, 5] Problems occurring after discharge may result in high rates of rehospitalization and unscheduled visits to healthcare providers.[6, 7, 8, 9, 10] Numerous investigators have tried to identify patients who are at increased risk for rehospitalizations within 30 days of discharge, and many studies have examined whether various interventions could decrease these adverse events (summarized in Hansen et al.[11]). An increasing fraction of patients discharged by medicine and surgery services have some or all of their care supervised by hospitalists. Thus, hospitals increasingly look to hospitalists for ways to reduce rehospitalizations.

Patients discharged from our hospital are instructed to call an advice line (AL) if and when questions or concerns arise. Accordingly, we examined when these calls were made and what issues were raised, with the idea that the information collected might identify aspects of our discharge processes that needed improvement.

METHODS

RESULTS

During the 1‐year study period, 19,303 unique patients were discharged home with instructions regarding the use of the AL. A total of 310 patients called the AL and reported being hospitalized or having surgery within the preceding 30 days. Of these, 2 were excluded (1 who was incarcerated and 1 who was discharged to a skilled nursing facility), leaving 308 patients in the cohort. This represented 1.5% of the total number of unduplicated patients discharged during this same time period (minus the exclusions described above). The large majority of the calls (277/308, 90%) came directly from patients. The remaining 10% came from a proxy, usually a patient's family member. Compared with patients who were discharged during the same time period who did not call the AL, those who called were more likely to speak English, less likely to speak Spanish, more likely to be medically indigent, had slightly longer lengths of stays for their index hospitalization, and were more likely to be discharged from surgery than medicine services (particularly following inpatient surgery) (Table 1).

The median time from hospital discharge to the call was 3 days (interquartile range [IQR], 16), but 31% and 47% of calls occurred within 24 or 48 hours of discharge, respectively. Ten percent of patients called the AL the same day of discharge (Figure 1). We found no difference in timing of the calls as a function of discharging service.

Figure 1

The 308 patients reported a total of 612 problems or concerns (meanstandard deviation number of complaints per caller=21), the large majority of which (71%) were symptom‐related (Table 2). The most common symptom was uncontrolled pain, reported by 33% and 40% of patients discharged from medicine and surgery services, respectively. The next most common symptoms related to the gastrointestinal system and to surgical site issues in medicine and surgery patients, respectively (data not shown).

Sixty‐five patients, representing 21% of the cohort, reported 81 problems understanding or executing discharge instructions. No difference was observed between the fraction of these problems reported by patients from medicine versus surgery (19% and 22%, respectively, P=0.54).

Sixty‐five patients, again representing 21% of the cohort, reported 87 medication‐related problems, 20% from both the medicine and surgery services (P=0.99). Medicine patients more frequently reported difficulties understanding their medication instructions, whereas surgery patients more frequently reported lack of efficacy of medications, particularly with respect to pain control (data not shown).

Thirty percent of patients who called the AL were advised by the nurse to go to the emergency department immediately. Medicine patients were more likely to be triaged to the emergency department compared with surgery patients (45% vs 22%, P<0.0001).

The 30‐day readmission rates and the rates of unscheduled urgent or emergent care visits were higher for patients calling the AL compared with those who did not call (46/308, 15% vs 706/18,995, 4%, and 92/308, 30% vs 1303/18,995, 7%, respectively, both P<0.0001). Similar differences were found for patients discharged from medicine or surgery services who called the AL compared with those who did not (data not shown, both P<0.0001). The median number of days between AL call and rehospitalization was 0 (IQR, 02) and 1 (IQR, 08) for medicine and surgery patients, respectively. Ninety‐three percent of rehospitalizations were related to the index hospitalization, and 78% of patients who were readmitted had no outpatient encounter in the interim between discharge and rehospitalization.

DISCUSSION

We investigated the source and nature of patient telephone calls to an AL following a hospitalization or surgery, and our data revealed the following important findings: (1) nearly one‐half of the calls to the AL occurred within the first 48 hours following discharge; (2) the majority of the calls came from surgery patients, and a greater fraction of patients discharged from surgery services called the AL than patients discharged from medicine services; (3) the most common issues were uncontrolled pain, questions about medications, and problems understanding or executing aftercare instructions (particularly pertaining to the care of surgical wounds); and (4) patients calling the AL had higher rates of 30‐day rehospitalization and of unscheduled urgent or emergent care visits.

The utilization of our patient‐initiated call line was only 1.5%, which was on the low end of the 1% to 10% reported in the literature.[7, 12] This can be attributed to a number of issues that are specific to our system. First, the discharge instructions provided to our patients stated that they should call their primary care provider or the AL if they had questions. Accordingly, because approximately 50% of our patients had a primary care provider in our system, some may have preferentially contacted their primary care provider rather than the AL. Second, the instructions stated that the patients should call if they were experiencing the symptoms listed on the instruction sheet, so those with other problems/complaints may not have called. Third, AL personnel identified patients as being in our cohort by asking if they had been discharged or underwent a surgical procedure within 30‐days of their call. This may have resulted in the under‐reporting of patients who were hospitalized or had outpatient surgical procedures. Fourth, there may have been a number of characteristics specific to patients in our system that reduced the frequency with which they utilized the AL (eg, access to telephones or other community providers).

Most previous studies of patient‐initiated call lines have included them as part of multi‐intervention pre‐ and/or postdischarge strategies.[7, 8, 9, 10, 11, 12, 13] One prior small study compared the information reported by 37 patients who called an AL with that elicited by nurse‐initiated patient contact.[12] The most frequently reported problems in this study were medication‐related issues (43%). However, this study only included medicine patients and did not document the proportion of calls occurring at various time intervals.

The problems we identified (in both medicine and surgery patients) have previously been described,[2, 3, 4, 13, 14, 15, 16] but all of the studies reporting these problems utilized calls that were initiated by health care providers to patients at various fixed intervals following discharge (ie, 730 days). Most of these used a scripted approach seeking responses to specific questions or outcomes, and the specific timing at which the problems arose was not addressed. In contrast, we examined unsolicited concerns expressed by patients calling an AL following discharge whenever they felt sufficient urgency to address whatever problems or questions arose. We found that a large fraction of calls occurred on the day of or within the first 48 hours following discharge, much earlier than when provider‐initiated calls in the studies cited above occurred. Accordingly, our results cannot be used to compare the utility of patient‐ versus provider‐initiated calls, or to suggest that other hospitals should create an AL system. Rather, we suggest that our findings might be complementary to those reported in studies of provider‐initiated calls and only propose that by examining calls placed by patients to ALs, problems with hospital discharge processes (some of which may result in increased rates of readmission) may be discovered.

The observation that such a large fraction of calls to our AL occurred within the first 48 hours following discharge, together with the fact that many of the questions asked or concerns raised pertained to issues that should have been discussed during the discharge process (eg, pain control, care of surgical wounds), suggests that suboptimal patient education was occurring prior to discharge as was suggested by Henderson and Zernike.[17] This finding has led us to expand our patient education processes prior to discharge on both medicine and surgery services. Because our hospitalists care for approximately 90% of the patients admitted to medicine services and are increasingly involved in the care of patients on surgery services, they are integrally involved with such quality improvement initiatives.

To our knowledge this is the first study in the literature that describes both medicine and surgery patients who call an AL because of problems or questions following hospital discharge, categorizes these problems, determines when the patients called following their discharge, and identifies those who called as being at increased risk for early rehospitalizations and unscheduled urgent or emergent care visits. Given the financial penalties issued to hospitals with high 30‐day readmission rates, these patients may warrant more attention than is customarily available from telephone call lines or during routine outpatient follow‐up. The majority of patients who called our AL had Medicare, Medicaid, or a commercial insurance, and, accordingly, may have been eligible for additional services such as home visits and/or expedited follow‐up appointments.

Our study has a number of limitations. First, it is a single‐center study, so the results might not generalize to other institutions. Second, because the study was performed in a university‐affiliated, public safety‐net hospital, patient characteristics and the rates and types of postdischarge concerns that we observed might differ from those encountered in different types of hospitals and/or from those in nonteaching institutions. We would suggest, however, that the idea of using concerns raised by patients discharged from any type of hospital in calls to ALs may similarly identify problems with that specific hospital's discharge processes. Third, the information collected from the AL came from summaries provided by nurses answering the calls rather than from actual transcripts. This could have resulted in insufficient or incorrect information pertaining to some of the variables assessed in Table 2. The information presented in Table 1, however, was obtained from our data warehouse after matching medical record numbers. Fourth, we could have underestimated the number of patients who had 30‐day rehospitalizations and/or unplanned for urgent or emergent care visits if patients sought care at other hospitals. Fifth, the number of patients calling the AL was too small to allow us to do any type of robust matching or multivariable analysis. Accordingly, the differences that appeared between patients who called and those who did not (ie, English speakers, being medically indigent, the length of stay for the index hospitalization and the discharging service) could be the result of inadequate matching or interactions among the variables. Although matching or multivariate analysis might have yielded different associations between patients who called the AL versus those who did not, those who called the AL still had an increased risk of readmission and urgent or emergent visits and may still benefit from targeted interventions. Finally, the fact that only 1.5% of unique patients who were discharged called the AL could have biased our results. Because only 55% and 53% of the patients who did or did not call the AL, respectively, saw primary care physicians within our system within the 3 years prior to their index hospitalization (P=0.679), the frequency of calls to the AL that we observed could have underestimated the frequency with which patients had contact with other care providers in the community.

In summary, information collected from patient‐initiated calls to our AL identified several aspects of our discharge processes that needed improvement. We concluded that our predischarge educational processes for both medicine and surgery services needed modification, especially with respect to pain management, which problems to expect after hospitalization or surgery, and how to deal with them. The high rates of 30‐day rehospitalization and of unscheduled urgent or emergent care visits among patients calling the AL identifies them as being at increased risk for these outcomes, although the likelihood of these events may be related to factors other than just calling the AL.

The period immediately following hospital discharge is particularly hazardous for patients.[1, 2, 3, 4, 5] Problems occurring after discharge may result in high rates of rehospitalization and unscheduled visits to healthcare providers.[6, 7, 8, 9, 10] Numerous investigators have tried to identify patients who are at increased risk for rehospitalizations within 30 days of discharge, and many studies have examined whether various interventions could decrease these adverse events (summarized in Hansen et al.[11]). An increasing fraction of patients discharged by medicine and surgery services have some or all of their care supervised by hospitalists. Thus, hospitals increasingly look to hospitalists for ways to reduce rehospitalizations.

Patients discharged from our hospital are instructed to call an advice line (AL) if and when questions or concerns arise. Accordingly, we examined when these calls were made and what issues were raised, with the idea that the information collected might identify aspects of our discharge processes that needed improvement.

METHODS

RESULTS

During the 1‐year study period, 19,303 unique patients were discharged home with instructions regarding the use of the AL. A total of 310 patients called the AL and reported being hospitalized or having surgery within the preceding 30 days. Of these, 2 were excluded (1 who was incarcerated and 1 who was discharged to a skilled nursing facility), leaving 308 patients in the cohort. This represented 1.5% of the total number of unduplicated patients discharged during this same time period (minus the exclusions described above). The large majority of the calls (277/308, 90%) came directly from patients. The remaining 10% came from a proxy, usually a patient's family member. Compared with patients who were discharged during the same time period who did not call the AL, those who called were more likely to speak English, less likely to speak Spanish, more likely to be medically indigent, had slightly longer lengths of stays for their index hospitalization, and were more likely to be discharged from surgery than medicine services (particularly following inpatient surgery) (Table 1).

The median time from hospital discharge to the call was 3 days (interquartile range [IQR], 16), but 31% and 47% of calls occurred within 24 or 48 hours of discharge, respectively. Ten percent of patients called the AL the same day of discharge (Figure 1). We found no difference in timing of the calls as a function of discharging service.

Figure 1

The 308 patients reported a total of 612 problems or concerns (meanstandard deviation number of complaints per caller=21), the large majority of which (71%) were symptom‐related (Table 2). The most common symptom was uncontrolled pain, reported by 33% and 40% of patients discharged from medicine and surgery services, respectively. The next most common symptoms related to the gastrointestinal system and to surgical site issues in medicine and surgery patients, respectively (data not shown).

Sixty‐five patients, representing 21% of the cohort, reported 81 problems understanding or executing discharge instructions. No difference was observed between the fraction of these problems reported by patients from medicine versus surgery (19% and 22%, respectively, P=0.54).

Sixty‐five patients, again representing 21% of the cohort, reported 87 medication‐related problems, 20% from both the medicine and surgery services (P=0.99). Medicine patients more frequently reported difficulties understanding their medication instructions, whereas surgery patients more frequently reported lack of efficacy of medications, particularly with respect to pain control (data not shown).

Thirty percent of patients who called the AL were advised by the nurse to go to the emergency department immediately. Medicine patients were more likely to be triaged to the emergency department compared with surgery patients (45% vs 22%, P<0.0001).

The 30‐day readmission rates and the rates of unscheduled urgent or emergent care visits were higher for patients calling the AL compared with those who did not call (46/308, 15% vs 706/18,995, 4%, and 92/308, 30% vs 1303/18,995, 7%, respectively, both P<0.0001). Similar differences were found for patients discharged from medicine or surgery services who called the AL compared with those who did not (data not shown, both P<0.0001). The median number of days between AL call and rehospitalization was 0 (IQR, 02) and 1 (IQR, 08) for medicine and surgery patients, respectively. Ninety‐three percent of rehospitalizations were related to the index hospitalization, and 78% of patients who were readmitted had no outpatient encounter in the interim between discharge and rehospitalization.

DISCUSSION

We investigated the source and nature of patient telephone calls to an AL following a hospitalization or surgery, and our data revealed the following important findings: (1) nearly one‐half of the calls to the AL occurred within the first 48 hours following discharge; (2) the majority of the calls came from surgery patients, and a greater fraction of patients discharged from surgery services called the AL than patients discharged from medicine services; (3) the most common issues were uncontrolled pain, questions about medications, and problems understanding or executing aftercare instructions (particularly pertaining to the care of surgical wounds); and (4) patients calling the AL had higher rates of 30‐day rehospitalization and of unscheduled urgent or emergent care visits.

The utilization of our patient‐initiated call line was only 1.5%, which was on the low end of the 1% to 10% reported in the literature.[7, 12] This can be attributed to a number of issues that are specific to our system. First, the discharge instructions provided to our patients stated that they should call their primary care provider or the AL if they had questions. Accordingly, because approximately 50% of our patients had a primary care provider in our system, some may have preferentially contacted their primary care provider rather than the AL. Second, the instructions stated that the patients should call if they were experiencing the symptoms listed on the instruction sheet, so those with other problems/complaints may not have called. Third, AL personnel identified patients as being in our cohort by asking if they had been discharged or underwent a surgical procedure within 30‐days of their call. This may have resulted in the under‐reporting of patients who were hospitalized or had outpatient surgical procedures. Fourth, there may have been a number of characteristics specific to patients in our system that reduced the frequency with which they utilized the AL (eg, access to telephones or other community providers).

Most previous studies of patient‐initiated call lines have included them as part of multi‐intervention pre‐ and/or postdischarge strategies.[7, 8, 9, 10, 11, 12, 13] One prior small study compared the information reported by 37 patients who called an AL with that elicited by nurse‐initiated patient contact.[12] The most frequently reported problems in this study were medication‐related issues (43%). However, this study only included medicine patients and did not document the proportion of calls occurring at various time intervals.

The problems we identified (in both medicine and surgery patients) have previously been described,[2, 3, 4, 13, 14, 15, 16] but all of the studies reporting these problems utilized calls that were initiated by health care providers to patients at various fixed intervals following discharge (ie, 730 days). Most of these used a scripted approach seeking responses to specific questions or outcomes, and the specific timing at which the problems arose was not addressed. In contrast, we examined unsolicited concerns expressed by patients calling an AL following discharge whenever they felt sufficient urgency to address whatever problems or questions arose. We found that a large fraction of calls occurred on the day of or within the first 48 hours following discharge, much earlier than when provider‐initiated calls in the studies cited above occurred. Accordingly, our results cannot be used to compare the utility of patient‐ versus provider‐initiated calls, or to suggest that other hospitals should create an AL system. Rather, we suggest that our findings might be complementary to those reported in studies of provider‐initiated calls and only propose that by examining calls placed by patients to ALs, problems with hospital discharge processes (some of which may result in increased rates of readmission) may be discovered.

The observation that such a large fraction of calls to our AL occurred within the first 48 hours following discharge, together with the fact that many of the questions asked or concerns raised pertained to issues that should have been discussed during the discharge process (eg, pain control, care of surgical wounds), suggests that suboptimal patient education was occurring prior to discharge as was suggested by Henderson and Zernike.[17] This finding has led us to expand our patient education processes prior to discharge on both medicine and surgery services. Because our hospitalists care for approximately 90% of the patients admitted to medicine services and are increasingly involved in the care of patients on surgery services, they are integrally involved with such quality improvement initiatives.

To our knowledge this is the first study in the literature that describes both medicine and surgery patients who call an AL because of problems or questions following hospital discharge, categorizes these problems, determines when the patients called following their discharge, and identifies those who called as being at increased risk for early rehospitalizations and unscheduled urgent or emergent care visits. Given the financial penalties issued to hospitals with high 30‐day readmission rates, these patients may warrant more attention than is customarily available from telephone call lines or during routine outpatient follow‐up. The majority of patients who called our AL had Medicare, Medicaid, or a commercial insurance, and, accordingly, may have been eligible for additional services such as home visits and/or expedited follow‐up appointments.

Our study has a number of limitations. First, it is a single‐center study, so the results might not generalize to other institutions. Second, because the study was performed in a university‐affiliated, public safety‐net hospital, patient characteristics and the rates and types of postdischarge concerns that we observed might differ from those encountered in different types of hospitals and/or from those in nonteaching institutions. We would suggest, however, that the idea of using concerns raised by patients discharged from any type of hospital in calls to ALs may similarly identify problems with that specific hospital's discharge processes. Third, the information collected from the AL came from summaries provided by nurses answering the calls rather than from actual transcripts. This could have resulted in insufficient or incorrect information pertaining to some of the variables assessed in Table 2. The information presented in Table 1, however, was obtained from our data warehouse after matching medical record numbers. Fourth, we could have underestimated the number of patients who had 30‐day rehospitalizations and/or unplanned for urgent or emergent care visits if patients sought care at other hospitals. Fifth, the number of patients calling the AL was too small to allow us to do any type of robust matching or multivariable analysis. Accordingly, the differences that appeared between patients who called and those who did not (ie, English speakers, being medically indigent, the length of stay for the index hospitalization and the discharging service) could be the result of inadequate matching or interactions among the variables. Although matching or multivariate analysis might have yielded different associations between patients who called the AL versus those who did not, those who called the AL still had an increased risk of readmission and urgent or emergent visits and may still benefit from targeted interventions. Finally, the fact that only 1.5% of unique patients who were discharged called the AL could have biased our results. Because only 55% and 53% of the patients who did or did not call the AL, respectively, saw primary care physicians within our system within the 3 years prior to their index hospitalization (P=0.679), the frequency of calls to the AL that we observed could have underestimated the frequency with which patients had contact with other care providers in the community.

In summary, information collected from patient‐initiated calls to our AL identified several aspects of our discharge processes that needed improvement. We concluded that our predischarge educational processes for both medicine and surgery services needed modification, especially with respect to pain management, which problems to expect after hospitalization or surgery, and how to deal with them. The high rates of 30‐day rehospitalization and of unscheduled urgent or emergent care visits among patients calling the AL identifies them as being at increased risk for these outcomes, although the likelihood of these events may be related to factors other than just calling the AL.

The period immediately following hospital discharge is particularly hazardous for patients.[1, 2, 3, 4, 5] Problems occurring after discharge may result in high rates of rehospitalization and unscheduled visits to healthcare providers.[6, 7, 8, 9, 10] Numerous investigators have tried to identify patients who are at increased risk for rehospitalizations within 30 days of discharge, and many studies have examined whether various interventions could decrease these adverse events (summarized in Hansen et al.[11]). An increasing fraction of patients discharged by medicine and surgery services have some or all of their care supervised by hospitalists. Thus, hospitals increasingly look to hospitalists for ways to reduce rehospitalizations.

Patients discharged from our hospital are instructed to call an advice line (AL) if and when questions or concerns arise. Accordingly, we examined when these calls were made and what issues were raised, with the idea that the information collected might identify aspects of our discharge processes that needed improvement.

METHODS

RESULTS

During the 1‐year study period, 19,303 unique patients were discharged home with instructions regarding the use of the AL. A total of 310 patients called the AL and reported being hospitalized or having surgery within the preceding 30 days. Of these, 2 were excluded (1 who was incarcerated and 1 who was discharged to a skilled nursing facility), leaving 308 patients in the cohort. This represented 1.5% of the total number of unduplicated patients discharged during this same time period (minus the exclusions described above). The large majority of the calls (277/308, 90%) came directly from patients. The remaining 10% came from a proxy, usually a patient's family member. Compared with patients who were discharged during the same time period who did not call the AL, those who called were more likely to speak English, less likely to speak Spanish, more likely to be medically indigent, had slightly longer lengths of stays for their index hospitalization, and were more likely to be discharged from surgery than medicine services (particularly following inpatient surgery) (Table 1).

The median time from hospital discharge to the call was 3 days (interquartile range [IQR], 16), but 31% and 47% of calls occurred within 24 or 48 hours of discharge, respectively. Ten percent of patients called the AL the same day of discharge (Figure 1). We found no difference in timing of the calls as a function of discharging service.

Figure 1

The 308 patients reported a total of 612 problems or concerns (meanstandard deviation number of complaints per caller=21), the large majority of which (71%) were symptom‐related (Table 2). The most common symptom was uncontrolled pain, reported by 33% and 40% of patients discharged from medicine and surgery services, respectively. The next most common symptoms related to the gastrointestinal system and to surgical site issues in medicine and surgery patients, respectively (data not shown).

Sixty‐five patients, representing 21% of the cohort, reported 81 problems understanding or executing discharge instructions. No difference was observed between the fraction of these problems reported by patients from medicine versus surgery (19% and 22%, respectively, P=0.54).

Sixty‐five patients, again representing 21% of the cohort, reported 87 medication‐related problems, 20% from both the medicine and surgery services (P=0.99). Medicine patients more frequently reported difficulties understanding their medication instructions, whereas surgery patients more frequently reported lack of efficacy of medications, particularly with respect to pain control (data not shown).

Thirty percent of patients who called the AL were advised by the nurse to go to the emergency department immediately. Medicine patients were more likely to be triaged to the emergency department compared with surgery patients (45% vs 22%, P<0.0001).

The 30‐day readmission rates and the rates of unscheduled urgent or emergent care visits were higher for patients calling the AL compared with those who did not call (46/308, 15% vs 706/18,995, 4%, and 92/308, 30% vs 1303/18,995, 7%, respectively, both P<0.0001). Similar differences were found for patients discharged from medicine or surgery services who called the AL compared with those who did not (data not shown, both P<0.0001). The median number of days between AL call and rehospitalization was 0 (IQR, 02) and 1 (IQR, 08) for medicine and surgery patients, respectively. Ninety‐three percent of rehospitalizations were related to the index hospitalization, and 78% of patients who were readmitted had no outpatient encounter in the interim between discharge and rehospitalization.

DISCUSSION

We investigated the source and nature of patient telephone calls to an AL following a hospitalization or surgery, and our data revealed the following important findings: (1) nearly one‐half of the calls to the AL occurred within the first 48 hours following discharge; (2) the majority of the calls came from surgery patients, and a greater fraction of patients discharged from surgery services called the AL than patients discharged from medicine services; (3) the most common issues were uncontrolled pain, questions about medications, and problems understanding or executing aftercare instructions (particularly pertaining to the care of surgical wounds); and (4) patients calling the AL had higher rates of 30‐day rehospitalization and of unscheduled urgent or emergent care visits.

The utilization of our patient‐initiated call line was only 1.5%, which was on the low end of the 1% to 10% reported in the literature.[7, 12] This can be attributed to a number of issues that are specific to our system. First, the discharge instructions provided to our patients stated that they should call their primary care provider or the AL if they had questions. Accordingly, because approximately 50% of our patients had a primary care provider in our system, some may have preferentially contacted their primary care provider rather than the AL. Second, the instructions stated that the patients should call if they were experiencing the symptoms listed on the instruction sheet, so those with other problems/complaints may not have called. Third, AL personnel identified patients as being in our cohort by asking if they had been discharged or underwent a surgical procedure within 30‐days of their call. This may have resulted in the under‐reporting of patients who were hospitalized or had outpatient surgical procedures. Fourth, there may have been a number of characteristics specific to patients in our system that reduced the frequency with which they utilized the AL (eg, access to telephones or other community providers).

Most previous studies of patient‐initiated call lines have included them as part of multi‐intervention pre‐ and/or postdischarge strategies.[7, 8, 9, 10, 11, 12, 13] One prior small study compared the information reported by 37 patients who called an AL with that elicited by nurse‐initiated patient contact.[12] The most frequently reported problems in this study were medication‐related issues (43%). However, this study only included medicine patients and did not document the proportion of calls occurring at various time intervals.

The problems we identified (in both medicine and surgery patients) have previously been described,[2, 3, 4, 13, 14, 15, 16] but all of the studies reporting these problems utilized calls that were initiated by health care providers to patients at various fixed intervals following discharge (ie, 730 days). Most of these used a scripted approach seeking responses to specific questions or outcomes, and the specific timing at which the problems arose was not addressed. In contrast, we examined unsolicited concerns expressed by patients calling an AL following discharge whenever they felt sufficient urgency to address whatever problems or questions arose. We found that a large fraction of calls occurred on the day of or within the first 48 hours following discharge, much earlier than when provider‐initiated calls in the studies cited above occurred. Accordingly, our results cannot be used to compare the utility of patient‐ versus provider‐initiated calls, or to suggest that other hospitals should create an AL system. Rather, we suggest that our findings might be complementary to those reported in studies of provider‐initiated calls and only propose that by examining calls placed by patients to ALs, problems with hospital discharge processes (some of which may result in increased rates of readmission) may be discovered.

The observation that such a large fraction of calls to our AL occurred within the first 48 hours following discharge, together with the fact that many of the questions asked or concerns raised pertained to issues that should have been discussed during the discharge process (eg, pain control, care of surgical wounds), suggests that suboptimal patient education was occurring prior to discharge as was suggested by Henderson and Zernike.[17] This finding has led us to expand our patient education processes prior to discharge on both medicine and surgery services. Because our hospitalists care for approximately 90% of the patients admitted to medicine services and are increasingly involved in the care of patients on surgery services, they are integrally involved with such quality improvement initiatives.

To our knowledge this is the first study in the literature that describes both medicine and surgery patients who call an AL because of problems or questions following hospital discharge, categorizes these problems, determines when the patients called following their discharge, and identifies those who called as being at increased risk for early rehospitalizations and unscheduled urgent or emergent care visits. Given the financial penalties issued to hospitals with high 30‐day readmission rates, these patients may warrant more attention than is customarily available from telephone call lines or during routine outpatient follow‐up. The majority of patients who called our AL had Medicare, Medicaid, or a commercial insurance, and, accordingly, may have been eligible for additional services such as home visits and/or expedited follow‐up appointments.

Our study has a number of limitations. First, it is a single‐center study, so the results might not generalize to other institutions. Second, because the study was performed in a university‐affiliated, public safety‐net hospital, patient characteristics and the rates and types of postdischarge concerns that we observed might differ from those encountered in different types of hospitals and/or from those in nonteaching institutions. We would suggest, however, that the idea of using concerns raised by patients discharged from any type of hospital in calls to ALs may similarly identify problems with that specific hospital's discharge processes. Third, the information collected from the AL came from summaries provided by nurses answering the calls rather than from actual transcripts. This could have resulted in insufficient or incorrect information pertaining to some of the variables assessed in Table 2. The information presented in Table 1, however, was obtained from our data warehouse after matching medical record numbers. Fourth, we could have underestimated the number of patients who had 30‐day rehospitalizations and/or unplanned for urgent or emergent care visits if patients sought care at other hospitals. Fifth, the number of patients calling the AL was too small to allow us to do any type of robust matching or multivariable analysis. Accordingly, the differences that appeared between patients who called and those who did not (ie, English speakers, being medically indigent, the length of stay for the index hospitalization and the discharging service) could be the result of inadequate matching or interactions among the variables. Although matching or multivariate analysis might have yielded different associations between patients who called the AL versus those who did not, those who called the AL still had an increased risk of readmission and urgent or emergent visits and may still benefit from targeted interventions. Finally, the fact that only 1.5% of unique patients who were discharged called the AL could have biased our results. Because only 55% and 53% of the patients who did or did not call the AL, respectively, saw primary care physicians within our system within the 3 years prior to their index hospitalization (P=0.679), the frequency of calls to the AL that we observed could have underestimated the frequency with which patients had contact with other care providers in the community.

In summary, information collected from patient‐initiated calls to our AL identified several aspects of our discharge processes that needed improvement. We concluded that our predischarge educational processes for both medicine and surgery services needed modification, especially with respect to pain management, which problems to expect after hospitalization or surgery, and how to deal with them. The high rates of 30‐day rehospitalization and of unscheduled urgent or emergent care visits among patients calling the AL identifies them as being at increased risk for these outcomes, although the likelihood of these events may be related to factors other than just calling the AL.

A curbside consultation is an informal process whereby a consultant is asked to provide information or advice about a patient's care without doing a formal assessment of the patient.14 Curbside consultations are common in the practice of medicine2, 3, 5 and are frequently requested by physicians caring for hospitalized patients. Several surveys have documented the quantity of curbside consultations requested of various subspecialties, the types of questions asked, the time it takes to respond, and physicians' perceptions about the quality of the information exchanged.111 While curbside consultations have a number of advantages, physicians' perceptions are that the information conveyed may be inaccurate or incomplete and that the advice offered may be erroneous.13, 5, 10, 12, 13

Cartmill and White14 performed a random audit of 10% of the telephone referrals they received for neurosurgical consultation over a 1‐year period and noted discrepancies between the Glascow Coma Scores reported during the telephone referrals and those noted in the medical records, but the frequency of these discrepancies was not reported. To our knowledge, no studies have compared the quality of the information provided in curbside consultations with that obtained in formal consultations that included direct face‐to‐face patient evaluations and primary data collection, and whether the advice provided in curbside and formal consultations on the same patient differed.

We performed a prospective cohort study to compare the information received by hospitalists during curbside consultations on hospitalized patients, with that obtained from formal consultations done the same day on the same patients, by different hospitalists who were unaware of any details regarding the curbside consultation. We also compared the advice provided by the 2 hospitalists following their curbside and formal consultations. Our hypotheses were that the information received during curbside consultations was frequently inaccurate or incomplete, that the recommendations made after the formal consultation would frequently differ from those made in the curbside consultation, and that these differences would have important implications on patient care.

METHODS

This was a quality improvement study conducted at Denver Health, a 500‐bed university‐affiliated urban safety net hospital from January 10, 2011 to January 9, 2012. The study design was a prospective cohort that included all curbside consultations on hospitalized patients received between 7 _AM and 3 _PM, on intermittently selected weekdays, by the Internal Medicine Consultation Service that was staffed by 18 hospitalists. Data were collected intermittently based upon hospitalist availability and was done to limit potential alterations in the consulting practices of the providers requesting consultations.

Consultations were defined as being curbside when the consulting provider asked for advice, suggestions, or opinions about a patient's care but did not ask the hospitalist to see the patient.15, 15 Consultations pertaining to administrative issues (eg, whether a patient should be admitted to an intensive care bed as opposed to an acute care floor bed) or on patients who were already being followed by a hospitalist were excluded.

The hospitalist receiving the curbside consultation was allowed to ask questions as they normally would, but could not verify the accuracy of the information received (eg, could not review any portion of the patient's medical record, such as notes or lab data). A standardized data collection sheet was used to record the service and level of training of the requesting provider, the medical issue(s) of concern, all clinical data offered by the provider, the number of questions asked by the hospitalist of the provider, and whether, on the basis of the information provided, the hospitalist felt that the question(s) being asked was (were) of sufficient complexity that a formal consultation should occur. The hospitalist then offered advice based upon the information given during the curbside consultation.

After completing the curbside consultation, the hospitalist requested verbal permission from the requesting provider to perform a formal consultation. If the request was approved, the hospitalist performing the curbside consultation contacted a different hospitalist who performed the formal consultation within the next few hours. The only information given to the second hospitalist was the patient's identifiers and the clinical question(s) being asked. The formal consultation included a complete face‐to‐face history and physical examination, a review of the patient's medical record, documentation of the provider's findings, and recommendations for care.

Upon completion of the formal consultation, the hospitalists who performed the curbside and the formal consultations met to review the advice each gave to the requesting provider and the information on which this advice was based. The 2 hospitalists jointly determined the following: (a) whether the information received during the curbside consultation was correct and complete, (b) whether the advice provided in the formal consultation differed from that provided in the curbside consultation, (c) whether the advice provided in the formal consultation dealt with issues other than one(s) leading to the curbside consultation, (d) whether differences in the recommendations given in the curbside versus the formal consultation changed patient management in a meaningful way, and (e) whether the curbside consultation alone was felt to be sufficient.

Information obtained by the hospitalist performing the formal consultation that was different from, or not included in, the information recorded during the curbside consultation was considered to be incorrect or incomplete, respectively. A change in management was defined as an alteration in the direction or type of care that the patient would have received as a result of the advice being given. A pulmonary and critical care physician, with >35 years of experience in inpatient medicine, reviewed the information provided in the curbside and formal consultations, and independently assessed whether the curbside consultation alone would have been sufficient and whether the formal consultation changed management.

Curbside consultations were neither solicited nor discouraged during the course of the study. The provider requesting the curbside consultation was not informed or debriefed about the study in an attempt to avoid affecting future consultation practices from that provider or service.

Associations were sought between the frequency of inaccurate or incomplete data and the requesting service and provider, the consultative category and medical issue, the number of questions asked by the hospitalist during the curbside consultation, and whether the hospitalist doing the curbside consultation thought that formal consultation was needed. A chi‐square test was used to analyze all associations. A P value of <0.05 was considered significant. All analyses were performed using SAS Enterprise Guide 4.3 (SAS Institute, Inc, Cary, NC) software. The study was approved by the Colorado Multiple Institutional Review Board.

RESULTS

Fifty curbside consultations were requested on a total of 215 study days. The requesting service declined formal consultation in 3 instances, leaving 47 curbside consultations that had a formal consultation. Curbside consultations came from a variety of services and providers, and addressed a variety of issues and concerns (Table 1).

The hospitalists asked 0 to 2 questions during 8/47 (17%) of the curbside consultations, 3 to 5 questions during 26/47 (55%) consultations, and more than 5 questions during 13/47 (28%). Based on the information received during the curbside consultations, the hospitalists thought that the curbside consultations were insufficient for 18/47 (38%) of patients. In all instances, the opinions of the 2 hospitalists concurred with respect to this conclusion, and the independent reviewer agreed with this assessment in 17 of these 18 (94%).

The advice rendered in the formal consultations differed from that provided in 26/47 (55%) of the curbside consultations, and the formal consultation was thought to have changed management for 28/47 (60%) of patients (Table 2). The independent reviewer thought that the advice provided in the formal consultations changed management in 29/47 (62%) of the cases, and in 24/28 cases (86%) where the hospitalist felt that the formal consult changed management.

Information was felt to be inaccurate or incomplete in 24/47 (51%) of the curbside consultations (13/47 inaccurate, 16/47 incomplete, 5/47 both inaccurate and incomplete), and when inaccurate or incomplete information was obtained, the advice given in the formal consultations more commonly differed from that provided in the curbside consultation (19/24, 79% vs 7/23, 30%; P < 0.001), and was more commonly felt to change management (22/24, 92% vs 6/23, 26%; P < 0.0001) (Table 2). No association was found between whether the curbside consultation contained complete or accurate information and the consulting service from which the curbside originated, the consulting provider, the consultative aspect(s) or medical issue(s) addressed, the number of questions asked by the hospitalist during the curbside consultation, nor whether the hospitalists felt that a formal consultation was needed.

DISCUSSION

The important findings of this study are that (a) the recommendations made by hospitalists in curbside versus formal consultations on the same patient frequently differ, (b) these differences frequently result in changes in clinical management, (c) the information presented in curbside consultations by providers is frequently inaccurate or incomplete, regardless of the providers specialty or seniority, (d) when inaccurate or incomplete information is received, the recommendations made in curbside and formal consultations differ more frequently, and (e) we found no way to predict whether the information provided in a curbside consultation was likely to be inaccurate or incomplete.

Our hospitalists thought that 38% of the curbside consultations they received should have had formal consultations. Manian and McKinsey7 reported that as many as 53% of questions asked of infectious disease consultants were thought to be too complex to be addressed in an informal consultation. Others, however, report that only 11%33% of curbside consultations were thought to require formal consultation.1, 9, 10, 16 Our hospitalists asked 3 or more questions of the consulting providers in more than 80% of the curbside consultations, suggesting that the curbside consultations we received might have had a higher complexity than those seen by others.

Our finding that information provided in curbside consultation was frequently inaccurate or incomplete is consistent with a number of previous studies reporting physicians' perceptions of the accuracy of curbside consultations.2, 3 Hospital medicine is not likely to be the only discipline affected by inaccurate curbside consultation practices, as surveys of specialists in infectious disease, gynecology, and neurosurgery report that practitioners in these disciplines have similar concerns.1, 10, 14 In a survey returned by 34 physicians, Myers1 found that 50% thought the information exchanged during curbside consultations was inaccurate, leading him to conclude that inaccuracies presented during curbside consultations required further study.

We found no way of predicting whether curbside consultations were likely to include inaccurate or incomplete information. This observation is consistent with the results of Bergus et al16 who found that the frequency of curbside consultations being converted to formal consultations was independent of the training status of the consulting physician, and with the data of Myers1 who found no way of predicting the likelihood that a curbside consultation should be converted to a formal consultation.

We found that formal consultations resulted in management changes more often than differences in recommendations (ie, 60% vs 55%, respectively). This small difference occurred because, on occasion, the formal consultations found issues to address other than the one(s) for which the curbside consultation was requested. In the majority of these instances, the management changes were minor and the curbside consultation was still felt to be sufficient.

In some instances, the advice given after the curbside and the formal consultations differed to only a minor extent (eg, varying recommendations for oral diabetes management). In other instances, however, the advice differed substantially (eg, change in antibiotic management in a septic patient with a multidrug resistant organism, when the original curbside question was for when to order a follow‐up chest roentgenogram for hypoxia; see Supporting Information, Appendix, in the online version of this article). In 26 patients (55%), formal consultation resulted in different medications being started or stopped, additional tests being performed, or different decisions being made about admission versus discharge.

Our study has a number of strengths. First, while a number of reports document that physicians' perceptions are that curbside consultations frequently contain errors,2, 3, 5, 12 to our knowledge this is the first study that prospectively compared the information collected and advice given in curbside versus formal consultation. Second, while this study was conducted as a quality improvement project, thereby requiring us to conclude that the results are not generalizable, the data presented were collected by 18 different hospitalists, reducing the potential of bias from an individual provider's knowledge base or practice. Third, there was excellent agreement between the independent reviewer and the 2 hospitalists who performed the curbside and formal consultations regarding whether a curbside consultation would have been sufficient, and whether the formal consultation changed patient management. Fourth, the study was conducted over a 1‐year period, which should have reduced potential bias arising from the increasing experience of residents requesting consultations as their training progressed.

Our study has several limitations. First, the number of curbside consultations we received during the study period (50 over 215 days) was lower than anticipated, and lower than the rates of consultation reported by others.1, 7, 9 This likely relates to the fact that, prior to beginning the study, Denver Health hospitalists already provided mandatory consultations for several surgical services (thereby reducing the number of curbside consultations received from these services), because curbside consultations received during evenings, nights, and weekends were not included in the study for reasons of convenience, and because we excluded all administrative curbside consultations. Our hospitalist service also provides consultative services 24 hours a day, thereby reducing the number of consultations received during daytime hours. Second, the frequency with which curbside consultations included inaccurate or incomplete information might be higher than what occurs in other hospitals, as Denver Health is an urban, university‐affiliated public hospital and the patients encountered may be more complex and trainees may be less adept at recognizing the information that would facilitate accurate curbside consultations (although we found no difference in the frequency with which inaccurate or incomplete information was provided as a function of the seniority of the requesting physician). Third, the disparity between curbside and formal consultations that we observed could have been biased by the Hawthorne effect. We attempted to address this by not providing the hospitalists who did the formal consultation with any information collected by the hospitalist involved with the curbside consultation, and by comparing the conclusions reached by the hospitalists performing the curbside and formal consultations with those of a third party reviewer. Fourth, while we found no association between the frequency of curbside consultations in which information was inaccurate or incomplete and the consulting service, there could be a selection bias of the consulting service requesting the curbside consultations as a result of the mandatory consultations already provided by our hospitalists. Finally, our study was not designed or adequately powered to determine why curbside consultations frequently have inaccurate or incomplete information.

In summary, we found that the information provided to hospitalists during a curbside consultation was often inaccurate and incomplete, and that these problems with information exchange adversely affected the accuracy of the resulting recommendations. While there are a number of advantages to curbside consultations,1, 3, 7, 10, 12, 13 our findings indicate that the risk associated with this practice is substantial.

A curbside consultation is an informal process whereby a consultant is asked to provide information or advice about a patient's care without doing a formal assessment of the patient.14 Curbside consultations are common in the practice of medicine2, 3, 5 and are frequently requested by physicians caring for hospitalized patients. Several surveys have documented the quantity of curbside consultations requested of various subspecialties, the types of questions asked, the time it takes to respond, and physicians' perceptions about the quality of the information exchanged.111 While curbside consultations have a number of advantages, physicians' perceptions are that the information conveyed may be inaccurate or incomplete and that the advice offered may be erroneous.13, 5, 10, 12, 13

Cartmill and White14 performed a random audit of 10% of the telephone referrals they received for neurosurgical consultation over a 1‐year period and noted discrepancies between the Glascow Coma Scores reported during the telephone referrals and those noted in the medical records, but the frequency of these discrepancies was not reported. To our knowledge, no studies have compared the quality of the information provided in curbside consultations with that obtained in formal consultations that included direct face‐to‐face patient evaluations and primary data collection, and whether the advice provided in curbside and formal consultations on the same patient differed.

We performed a prospective cohort study to compare the information received by hospitalists during curbside consultations on hospitalized patients, with that obtained from formal consultations done the same day on the same patients, by different hospitalists who were unaware of any details regarding the curbside consultation. We also compared the advice provided by the 2 hospitalists following their curbside and formal consultations. Our hypotheses were that the information received during curbside consultations was frequently inaccurate or incomplete, that the recommendations made after the formal consultation would frequently differ from those made in the curbside consultation, and that these differences would have important implications on patient care.

METHODS

This was a quality improvement study conducted at Denver Health, a 500‐bed university‐affiliated urban safety net hospital from January 10, 2011 to January 9, 2012. The study design was a prospective cohort that included all curbside consultations on hospitalized patients received between 7 _AM and 3 _PM, on intermittently selected weekdays, by the Internal Medicine Consultation Service that was staffed by 18 hospitalists. Data were collected intermittently based upon hospitalist availability and was done to limit potential alterations in the consulting practices of the providers requesting consultations.

Consultations were defined as being curbside when the consulting provider asked for advice, suggestions, or opinions about a patient's care but did not ask the hospitalist to see the patient.15, 15 Consultations pertaining to administrative issues (eg, whether a patient should be admitted to an intensive care bed as opposed to an acute care floor bed) or on patients who were already being followed by a hospitalist were excluded.

The hospitalist receiving the curbside consultation was allowed to ask questions as they normally would, but could not verify the accuracy of the information received (eg, could not review any portion of the patient's medical record, such as notes or lab data). A standardized data collection sheet was used to record the service and level of training of the requesting provider, the medical issue(s) of concern, all clinical data offered by the provider, the number of questions asked by the hospitalist of the provider, and whether, on the basis of the information provided, the hospitalist felt that the question(s) being asked was (were) of sufficient complexity that a formal consultation should occur. The hospitalist then offered advice based upon the information given during the curbside consultation.

After completing the curbside consultation, the hospitalist requested verbal permission from the requesting provider to perform a formal consultation. If the request was approved, the hospitalist performing the curbside consultation contacted a different hospitalist who performed the formal consultation within the next few hours. The only information given to the second hospitalist was the patient's identifiers and the clinical question(s) being asked. The formal consultation included a complete face‐to‐face history and physical examination, a review of the patient's medical record, documentation of the provider's findings, and recommendations for care.

Upon completion of the formal consultation, the hospitalists who performed the curbside and the formal consultations met to review the advice each gave to the requesting provider and the information on which this advice was based. The 2 hospitalists jointly determined the following: (a) whether the information received during the curbside consultation was correct and complete, (b) whether the advice provided in the formal consultation differed from that provided in the curbside consultation, (c) whether the advice provided in the formal consultation dealt with issues other than one(s) leading to the curbside consultation, (d) whether differences in the recommendations given in the curbside versus the formal consultation changed patient management in a meaningful way, and (e) whether the curbside consultation alone was felt to be sufficient.

Information obtained by the hospitalist performing the formal consultation that was different from, or not included in, the information recorded during the curbside consultation was considered to be incorrect or incomplete, respectively. A change in management was defined as an alteration in the direction or type of care that the patient would have received as a result of the advice being given. A pulmonary and critical care physician, with >35 years of experience in inpatient medicine, reviewed the information provided in the curbside and formal consultations, and independently assessed whether the curbside consultation alone would have been sufficient and whether the formal consultation changed management.

Curbside consultations were neither solicited nor discouraged during the course of the study. The provider requesting the curbside consultation was not informed or debriefed about the study in an attempt to avoid affecting future consultation practices from that provider or service.

Associations were sought between the frequency of inaccurate or incomplete data and the requesting service and provider, the consultative category and medical issue, the number of questions asked by the hospitalist during the curbside consultation, and whether the hospitalist doing the curbside consultation thought that formal consultation was needed. A chi‐square test was used to analyze all associations. A P value of <0.05 was considered significant. All analyses were performed using SAS Enterprise Guide 4.3 (SAS Institute, Inc, Cary, NC) software. The study was approved by the Colorado Multiple Institutional Review Board.

RESULTS

Fifty curbside consultations were requested on a total of 215 study days. The requesting service declined formal consultation in 3 instances, leaving 47 curbside consultations that had a formal consultation. Curbside consultations came from a variety of services and providers, and addressed a variety of issues and concerns (Table 1).

The hospitalists asked 0 to 2 questions during 8/47 (17%) of the curbside consultations, 3 to 5 questions during 26/47 (55%) consultations, and more than 5 questions during 13/47 (28%). Based on the information received during the curbside consultations, the hospitalists thought that the curbside consultations were insufficient for 18/47 (38%) of patients. In all instances, the opinions of the 2 hospitalists concurred with respect to this conclusion, and the independent reviewer agreed with this assessment in 17 of these 18 (94%).

The advice rendered in the formal consultations differed from that provided in 26/47 (55%) of the curbside consultations, and the formal consultation was thought to have changed management for 28/47 (60%) of patients (Table 2). The independent reviewer thought that the advice provided in the formal consultations changed management in 29/47 (62%) of the cases, and in 24/28 cases (86%) where the hospitalist felt that the formal consult changed management.

Information was felt to be inaccurate or incomplete in 24/47 (51%) of the curbside consultations (13/47 inaccurate, 16/47 incomplete, 5/47 both inaccurate and incomplete), and when inaccurate or incomplete information was obtained, the advice given in the formal consultations more commonly differed from that provided in the curbside consultation (19/24, 79% vs 7/23, 30%; P < 0.001), and was more commonly felt to change management (22/24, 92% vs 6/23, 26%; P < 0.0001) (Table 2). No association was found between whether the curbside consultation contained complete or accurate information and the consulting service from which the curbside originated, the consulting provider, the consultative aspect(s) or medical issue(s) addressed, the number of questions asked by the hospitalist during the curbside consultation, nor whether the hospitalists felt that a formal consultation was needed.

DISCUSSION

The important findings of this study are that (a) the recommendations made by hospitalists in curbside versus formal consultations on the same patient frequently differ, (b) these differences frequently result in changes in clinical management, (c) the information presented in curbside consultations by providers is frequently inaccurate or incomplete, regardless of the providers specialty or seniority, (d) when inaccurate or incomplete information is received, the recommendations made in curbside and formal consultations differ more frequently, and (e) we found no way to predict whether the information provided in a curbside consultation was likely to be inaccurate or incomplete.

Our hospitalists thought that 38% of the curbside consultations they received should have had formal consultations. Manian and McKinsey7 reported that as many as 53% of questions asked of infectious disease consultants were thought to be too complex to be addressed in an informal consultation. Others, however, report that only 11%33% of curbside consultations were thought to require formal consultation.1, 9, 10, 16 Our hospitalists asked 3 or more questions of the consulting providers in more than 80% of the curbside consultations, suggesting that the curbside consultations we received might have had a higher complexity than those seen by others.

Our finding that information provided in curbside consultation was frequently inaccurate or incomplete is consistent with a number of previous studies reporting physicians' perceptions of the accuracy of curbside consultations.2, 3 Hospital medicine is not likely to be the only discipline affected by inaccurate curbside consultation practices, as surveys of specialists in infectious disease, gynecology, and neurosurgery report that practitioners in these disciplines have similar concerns.1, 10, 14 In a survey returned by 34 physicians, Myers1 found that 50% thought the information exchanged during curbside consultations was inaccurate, leading him to conclude that inaccuracies presented during curbside consultations required further study.

We found no way of predicting whether curbside consultations were likely to include inaccurate or incomplete information. This observation is consistent with the results of Bergus et al16 who found that the frequency of curbside consultations being converted to formal consultations was independent of the training status of the consulting physician, and with the data of Myers1 who found no way of predicting the likelihood that a curbside consultation should be converted to a formal consultation.

We found that formal consultations resulted in management changes more often than differences in recommendations (ie, 60% vs 55%, respectively). This small difference occurred because, on occasion, the formal consultations found issues to address other than the one(s) for which the curbside consultation was requested. In the majority of these instances, the management changes were minor and the curbside consultation was still felt to be sufficient.

In some instances, the advice given after the curbside and the formal consultations differed to only a minor extent (eg, varying recommendations for oral diabetes management). In other instances, however, the advice differed substantially (eg, change in antibiotic management in a septic patient with a multidrug resistant organism, when the original curbside question was for when to order a follow‐up chest roentgenogram for hypoxia; see Supporting Information, Appendix, in the online version of this article). In 26 patients (55%), formal consultation resulted in different medications being started or stopped, additional tests being performed, or different decisions being made about admission versus discharge.

Our study has a number of strengths. First, while a number of reports document that physicians' perceptions are that curbside consultations frequently contain errors,2, 3, 5, 12 to our knowledge this is the first study that prospectively compared the information collected and advice given in curbside versus formal consultation. Second, while this study was conducted as a quality improvement project, thereby requiring us to conclude that the results are not generalizable, the data presented were collected by 18 different hospitalists, reducing the potential of bias from an individual provider's knowledge base or practice. Third, there was excellent agreement between the independent reviewer and the 2 hospitalists who performed the curbside and formal consultations regarding whether a curbside consultation would have been sufficient, and whether the formal consultation changed patient management. Fourth, the study was conducted over a 1‐year period, which should have reduced potential bias arising from the increasing experience of residents requesting consultations as their training progressed.

Our study has several limitations. First, the number of curbside consultations we received during the study period (50 over 215 days) was lower than anticipated, and lower than the rates of consultation reported by others.1, 7, 9 This likely relates to the fact that, prior to beginning the study, Denver Health hospitalists already provided mandatory consultations for several surgical services (thereby reducing the number of curbside consultations received from these services), because curbside consultations received during evenings, nights, and weekends were not included in the study for reasons of convenience, and because we excluded all administrative curbside consultations. Our hospitalist service also provides consultative services 24 hours a day, thereby reducing the number of consultations received during daytime hours. Second, the frequency with which curbside consultations included inaccurate or incomplete information might be higher than what occurs in other hospitals, as Denver Health is an urban, university‐affiliated public hospital and the patients encountered may be more complex and trainees may be less adept at recognizing the information that would facilitate accurate curbside consultations (although we found no difference in the frequency with which inaccurate or incomplete information was provided as a function of the seniority of the requesting physician). Third, the disparity between curbside and formal consultations that we observed could have been biased by the Hawthorne effect. We attempted to address this by not providing the hospitalists who did the formal consultation with any information collected by the hospitalist involved with the curbside consultation, and by comparing the conclusions reached by the hospitalists performing the curbside and formal consultations with those of a third party reviewer. Fourth, while we found no association between the frequency of curbside consultations in which information was inaccurate or incomplete and the consulting service, there could be a selection bias of the consulting service requesting the curbside consultations as a result of the mandatory consultations already provided by our hospitalists. Finally, our study was not designed or adequately powered to determine why curbside consultations frequently have inaccurate or incomplete information.

In summary, we found that the information provided to hospitalists during a curbside consultation was often inaccurate and incomplete, and that these problems with information exchange adversely affected the accuracy of the resulting recommendations. While there are a number of advantages to curbside consultations,1, 3, 7, 10, 12, 13 our findings indicate that the risk associated with this practice is substantial.

A curbside consultation is an informal process whereby a consultant is asked to provide information or advice about a patient's care without doing a formal assessment of the patient.14 Curbside consultations are common in the practice of medicine2, 3, 5 and are frequently requested by physicians caring for hospitalized patients. Several surveys have documented the quantity of curbside consultations requested of various subspecialties, the types of questions asked, the time it takes to respond, and physicians' perceptions about the quality of the information exchanged.111 While curbside consultations have a number of advantages, physicians' perceptions are that the information conveyed may be inaccurate or incomplete and that the advice offered may be erroneous.13, 5, 10, 12, 13

Cartmill and White14 performed a random audit of 10% of the telephone referrals they received for neurosurgical consultation over a 1‐year period and noted discrepancies between the Glascow Coma Scores reported during the telephone referrals and those noted in the medical records, but the frequency of these discrepancies was not reported. To our knowledge, no studies have compared the quality of the information provided in curbside consultations with that obtained in formal consultations that included direct face‐to‐face patient evaluations and primary data collection, and whether the advice provided in curbside and formal consultations on the same patient differed.

We performed a prospective cohort study to compare the information received by hospitalists during curbside consultations on hospitalized patients, with that obtained from formal consultations done the same day on the same patients, by different hospitalists who were unaware of any details regarding the curbside consultation. We also compared the advice provided by the 2 hospitalists following their curbside and formal consultations. Our hypotheses were that the information received during curbside consultations was frequently inaccurate or incomplete, that the recommendations made after the formal consultation would frequently differ from those made in the curbside consultation, and that these differences would have important implications on patient care.

METHODS

This was a quality improvement study conducted at Denver Health, a 500‐bed university‐affiliated urban safety net hospital from January 10, 2011 to January 9, 2012. The study design was a prospective cohort that included all curbside consultations on hospitalized patients received between 7 _AM and 3 _PM, on intermittently selected weekdays, by the Internal Medicine Consultation Service that was staffed by 18 hospitalists. Data were collected intermittently based upon hospitalist availability and was done to limit potential alterations in the consulting practices of the providers requesting consultations.

Consultations were defined as being curbside when the consulting provider asked for advice, suggestions, or opinions about a patient's care but did not ask the hospitalist to see the patient.15, 15 Consultations pertaining to administrative issues (eg, whether a patient should be admitted to an intensive care bed as opposed to an acute care floor bed) or on patients who were already being followed by a hospitalist were excluded.

The hospitalist receiving the curbside consultation was allowed to ask questions as they normally would, but could not verify the accuracy of the information received (eg, could not review any portion of the patient's medical record, such as notes or lab data). A standardized data collection sheet was used to record the service and level of training of the requesting provider, the medical issue(s) of concern, all clinical data offered by the provider, the number of questions asked by the hospitalist of the provider, and whether, on the basis of the information provided, the hospitalist felt that the question(s) being asked was (were) of sufficient complexity that a formal consultation should occur. The hospitalist then offered advice based upon the information given during the curbside consultation.

After completing the curbside consultation, the hospitalist requested verbal permission from the requesting provider to perform a formal consultation. If the request was approved, the hospitalist performing the curbside consultation contacted a different hospitalist who performed the formal consultation within the next few hours. The only information given to the second hospitalist was the patient's identifiers and the clinical question(s) being asked. The formal consultation included a complete face‐to‐face history and physical examination, a review of the patient's medical record, documentation of the provider's findings, and recommendations for care.

Upon completion of the formal consultation, the hospitalists who performed the curbside and the formal consultations met to review the advice each gave to the requesting provider and the information on which this advice was based. The 2 hospitalists jointly determined the following: (a) whether the information received during the curbside consultation was correct and complete, (b) whether the advice provided in the formal consultation differed from that provided in the curbside consultation, (c) whether the advice provided in the formal consultation dealt with issues other than one(s) leading to the curbside consultation, (d) whether differences in the recommendations given in the curbside versus the formal consultation changed patient management in a meaningful way, and (e) whether the curbside consultation alone was felt to be sufficient.

Information obtained by the hospitalist performing the formal consultation that was different from, or not included in, the information recorded during the curbside consultation was considered to be incorrect or incomplete, respectively. A change in management was defined as an alteration in the direction or type of care that the patient would have received as a result of the advice being given. A pulmonary and critical care physician, with >35 years of experience in inpatient medicine, reviewed the information provided in the curbside and formal consultations, and independently assessed whether the curbside consultation alone would have been sufficient and whether the formal consultation changed management.

Curbside consultations were neither solicited nor discouraged during the course of the study. The provider requesting the curbside consultation was not informed or debriefed about the study in an attempt to avoid affecting future consultation practices from that provider or service.

Associations were sought between the frequency of inaccurate or incomplete data and the requesting service and provider, the consultative category and medical issue, the number of questions asked by the hospitalist during the curbside consultation, and whether the hospitalist doing the curbside consultation thought that formal consultation was needed. A chi‐square test was used to analyze all associations. A P value of <0.05 was considered significant. All analyses were performed using SAS Enterprise Guide 4.3 (SAS Institute, Inc, Cary, NC) software. The study was approved by the Colorado Multiple Institutional Review Board.

RESULTS

Fifty curbside consultations were requested on a total of 215 study days. The requesting service declined formal consultation in 3 instances, leaving 47 curbside consultations that had a formal consultation. Curbside consultations came from a variety of services and providers, and addressed a variety of issues and concerns (Table 1).

The hospitalists asked 0 to 2 questions during 8/47 (17%) of the curbside consultations, 3 to 5 questions during 26/47 (55%) consultations, and more than 5 questions during 13/47 (28%). Based on the information received during the curbside consultations, the hospitalists thought that the curbside consultations were insufficient for 18/47 (38%) of patients. In all instances, the opinions of the 2 hospitalists concurred with respect to this conclusion, and the independent reviewer agreed with this assessment in 17 of these 18 (94%).

The advice rendered in the formal consultations differed from that provided in 26/47 (55%) of the curbside consultations, and the formal consultation was thought to have changed management for 28/47 (60%) of patients (Table 2). The independent reviewer thought that the advice provided in the formal consultations changed management in 29/47 (62%) of the cases, and in 24/28 cases (86%) where the hospitalist felt that the formal consult changed management.

Information was felt to be inaccurate or incomplete in 24/47 (51%) of the curbside consultations (13/47 inaccurate, 16/47 incomplete, 5/47 both inaccurate and incomplete), and when inaccurate or incomplete information was obtained, the advice given in the formal consultations more commonly differed from that provided in the curbside consultation (19/24, 79% vs 7/23, 30%; P < 0.001), and was more commonly felt to change management (22/24, 92% vs 6/23, 26%; P < 0.0001) (Table 2). No association was found between whether the curbside consultation contained complete or accurate information and the consulting service from which the curbside originated, the consulting provider, the consultative aspect(s) or medical issue(s) addressed, the number of questions asked by the hospitalist during the curbside consultation, nor whether the hospitalists felt that a formal consultation was needed.

DISCUSSION

The important findings of this study are that (a) the recommendations made by hospitalists in curbside versus formal consultations on the same patient frequently differ, (b) these differences frequently result in changes in clinical management, (c) the information presented in curbside consultations by providers is frequently inaccurate or incomplete, regardless of the providers specialty or seniority, (d) when inaccurate or incomplete information is received, the recommendations made in curbside and formal consultations differ more frequently, and (e) we found no way to predict whether the information provided in a curbside consultation was likely to be inaccurate or incomplete.

Our hospitalists thought that 38% of the curbside consultations they received should have had formal consultations. Manian and McKinsey7 reported that as many as 53% of questions asked of infectious disease consultants were thought to be too complex to be addressed in an informal consultation. Others, however, report that only 11%33% of curbside consultations were thought to require formal consultation.1, 9, 10, 16 Our hospitalists asked 3 or more questions of the consulting providers in more than 80% of the curbside consultations, suggesting that the curbside consultations we received might have had a higher complexity than those seen by others.

Our finding that information provided in curbside consultation was frequently inaccurate or incomplete is consistent with a number of previous studies reporting physicians' perceptions of the accuracy of curbside consultations.2, 3 Hospital medicine is not likely to be the only discipline affected by inaccurate curbside consultation practices, as surveys of specialists in infectious disease, gynecology, and neurosurgery report that practitioners in these disciplines have similar concerns.1, 10, 14 In a survey returned by 34 physicians, Myers1 found that 50% thought the information exchanged during curbside consultations was inaccurate, leading him to conclude that inaccuracies presented during curbside consultations required further study.

We found no way of predicting whether curbside consultations were likely to include inaccurate or incomplete information. This observation is consistent with the results of Bergus et al16 who found that the frequency of curbside consultations being converted to formal consultations was independent of the training status of the consulting physician, and with the data of Myers1 who found no way of predicting the likelihood that a curbside consultation should be converted to a formal consultation.

We found that formal consultations resulted in management changes more often than differences in recommendations (ie, 60% vs 55%, respectively). This small difference occurred because, on occasion, the formal consultations found issues to address other than the one(s) for which the curbside consultation was requested. In the majority of these instances, the management changes were minor and the curbside consultation was still felt to be sufficient.

In some instances, the advice given after the curbside and the formal consultations differed to only a minor extent (eg, varying recommendations for oral diabetes management). In other instances, however, the advice differed substantially (eg, change in antibiotic management in a septic patient with a multidrug resistant organism, when the original curbside question was for when to order a follow‐up chest roentgenogram for hypoxia; see Supporting Information, Appendix, in the online version of this article). In 26 patients (55%), formal consultation resulted in different medications being started or stopped, additional tests being performed, or different decisions being made about admission versus discharge.

Our study has a number of strengths. First, while a number of reports document that physicians' perceptions are that curbside consultations frequently contain errors,2, 3, 5, 12 to our knowledge this is the first study that prospectively compared the information collected and advice given in curbside versus formal consultation. Second, while this study was conducted as a quality improvement project, thereby requiring us to conclude that the results are not generalizable, the data presented were collected by 18 different hospitalists, reducing the potential of bias from an individual provider's knowledge base or practice. Third, there was excellent agreement between the independent reviewer and the 2 hospitalists who performed the curbside and formal consultations regarding whether a curbside consultation would have been sufficient, and whether the formal consultation changed patient management. Fourth, the study was conducted over a 1‐year period, which should have reduced potential bias arising from the increasing experience of residents requesting consultations as their training progressed.

Our study has several limitations. First, the number of curbside consultations we received during the study period (50 over 215 days) was lower than anticipated, and lower than the rates of consultation reported by others.1, 7, 9 This likely relates to the fact that, prior to beginning the study, Denver Health hospitalists already provided mandatory consultations for several surgical services (thereby reducing the number of curbside consultations received from these services), because curbside consultations received during evenings, nights, and weekends were not included in the study for reasons of convenience, and because we excluded all administrative curbside consultations. Our hospitalist service also provides consultative services 24 hours a day, thereby reducing the number of consultations received during daytime hours. Second, the frequency with which curbside consultations included inaccurate or incomplete information might be higher than what occurs in other hospitals, as Denver Health is an urban, university‐affiliated public hospital and the patients encountered may be more complex and trainees may be less adept at recognizing the information that would facilitate accurate curbside consultations (although we found no difference in the frequency with which inaccurate or incomplete information was provided as a function of the seniority of the requesting physician). Third, the disparity between curbside and formal consultations that we observed could have been biased by the Hawthorne effect. We attempted to address this by not providing the hospitalists who did the formal consultation with any information collected by the hospitalist involved with the curbside consultation, and by comparing the conclusions reached by the hospitalists performing the curbside and formal consultations with those of a third party reviewer. Fourth, while we found no association between the frequency of curbside consultations in which information was inaccurate or incomplete and the consulting service, there could be a selection bias of the consulting service requesting the curbside consultations as a result of the mandatory consultations already provided by our hospitalists. Finally, our study was not designed or adequately powered to determine why curbside consultations frequently have inaccurate or incomplete information.

In summary, we found that the information provided to hospitalists during a curbside consultation was often inaccurate and incomplete, and that these problems with information exchange adversely affected the accuracy of the resulting recommendations. While there are a number of advantages to curbside consultations,1, 3, 7, 10, 12, 13 our findings indicate that the risk associated with this practice is substantial.