Should We Curb the Curbside?

Marisha Burden, MDChief of Hospital MedicineDenver Health Medical CenterAssistant Professor of MedicineUniversity of Colorado School of Medicine

Curbside View

Formal Evaluation

Curbsides

Curbsides – Previous Studies

Quantity requested

Subspecialties consulted

Types of questions asked

Time spent

MD perceptions

Curbsides

Hypotheses

INCOMPLETE INFORMATION

DURING CURBSIDE

INCORRECT INFORMATION

DURING CURBSIDE

DIFFERENT ADVICE/RECSW/ FORMALCONSULT

MethodsDenver Health

Prospective Cohort

1 Year

Intermittent

18 Hospitalist Physicians

Definitions

Consulting provider asked for advice, suggestions, opinions

Did not ask hospitalist to see patient

Excluded: Administrative, patients already being seen by hospitalist

Curbsides – Our studyHospitalist A – “Curbside physician”

Formal ConsultHospitalist B – “Official Consultant”

“Consultee”

Methods

Curbside consults neither solicited, discouraged

Requesting providers not informed of study or debriefed

Analysis: Chi Square

Results

215 Study days

50 curbside consults

3 Formal consults declined

47 consults with both curbsides + formal consults

Requesting Service

Psychiatry ER Ob/gyn Neurology Other0

5

10

15

20

25

Num

ber o

f cur

bsid

es

8%11%

19%

45%

17%

Requesting Provider

Resident Intern Attending Other0

5

10

15

20

25

30

Cons

ults

(N)

53%

17%19%

11%

Consultative Concern

Treatment Evaluation Discharge? Diagnosis Lab0

5

10

15

20

25

30

35

Cons

ults

(N) 43%

28%

62%

21%

9%

**Consults could be listed in more than 1 category**

Medical Issue

Cardiac

Endoc

rine ID

Pulmon

ary GI

Electro

lyte/f

luid

Other

0

5

10

15

20

25

30

Cons

ults

(N)

57%

19% 17%13% 13%

49%

36%

**Consults could be listed in more than 1 category**

Number of Questions Asked

0 to 2 3 to 5 >50

5

10

15

20

25

30

Cons

ults

(N)

17%

55%

28%

Advice Given

Same Advice Different Advice0

5

10

15

20

25

30

Cons

ults

(N)

45%

55%

Management Changes

No change Change0

5

10

15

20

25

30

40%

60%3rd Reviewer29/47 (62%)

3rd Reviewer agreed in 24/28 (86%)

Minor: 18 (64%)

Major: 10 (36%)

Con

sults

(N)

Curbside Sufficient?

Curbside Sufficient Curbside Insuffient0

5

10

15

20

25

30

35

Cons

ults

(N)

62%

38%

3rd Reviewer agreed 17/18 (94%)

Information Accuracy

Accurate and Complete Inaccurate or incomplete0

5

10

15

20

25

30

49%51%

Incorrect: 8 (33%)

Incomplete: 11 (46%)

Incomplete& Inaccurate: 5 (21%)

Con

sults

(N)

Advice Given

Same Different Same Different0

2

4

6

8

10

12

14

16

18

20

Cons

ults

(N)

79%

21%

Information Accurate and

CompleteN=23

Information Inaccurate or Incomplete

N=24

P <0.001

70%

30%

Management Changes

Same Different Same Different0

5

10

15

20

25Information

Accurate and Complete

N=23

Information Inaccurate or Incomplete

N=24

P <0.0001

92%

8%

26%

74%

Minor: 100%Major: 0%

Major: 45%

Minor: 55%

Con

sults

(N)

Sufficiency of Curbside

Yes No Yes No0

5

10

15

20

25

Cons

ults

(N)

Information Accurate and

CompleteN=23

Information Inaccurate or Incomplete

N=24

P <0.0001

91%

9%

33%

67%

Curbside Sufficient

Examples – Management Changes

MINOR MAJOR

Post Hoc Analysis

Association No Association• Consulting Service• Consulting Provider• Medical Issue• Number of questions• Whether curbside was

felt to be sufficient• Consult issue

Strengths

1st prospective study

18 Hospitalists

Excellent 3rd Party Agreement

Conducted over 1 year

Weaknesses

Small N (50)

Teaching hospital

Urban safety net hospital

Hawthorne Effect

ConclusionsCurbside consults are associated with

considerable RISK that the advice provided and the resulting management decisions

made are incorrect.

InvestigatorsMarisha Burden*Ellen Sarcone*Angela KenistonBarbara StatlandJulie TaubRebecca AllynMark ReidLilia CervantesSarah Stella

Gaby FrankNick ScalettaSmitha ChadagaNancy MallerMargherita MascoloJeff ZouchaMary MaherRick Albert

*Co-Principal Investigators

Questions?

Marisha.Burden@dhha.org