Inpatient Subspecialty Consultations: A New Target for High-Value Pediatric Hospital Care?

D.M. is a 5-year-old boy admitted to the pediatric hospital medicine (PHM) service overnight with 7 days of persistent fever. His examination and laboratory studies in the emergency department are unrevealing. The next morning on inpatient rounds, the resident team lists a broad differential diagnosis and suggests placing subspecialty consultations for the infectious diseases, rheumatology, and oncology services for testing and management recommendations. However, the attending PHM physician disagrees, stating: “Why don’t we start the workup ourselves and involve subspecialists later if needed? It may add confusion to have too many ‘cooks in the kitchen.’” She discusses the case with an equally-experienced colleague, who states, “That’s interesting. I usually consult subspecialties right away for a patient like this. We’ll get him out the door faster if everyone is on the same page from the start.” This difference in opinion may sound familiar because subspecialty consultation is among the most ubiquitous practices in PHM. Yet we know remarkably little about the impact of subspecialty consultation in the pediatric inpatient setting on patients, families, and the broader health system. Although emerging data have questioned the value of certain consultation practices for hospitalized adults, hospitalists caring for children face unique considerations, including different risk calculations for an inherently vulnerable population, the integral role of families in clinical decision-making, and distinct clinical conditions. In this article, we outline: (1) what is known regarding consultation practice variation; (2) scenarios in which consultations add value to inpatient care; (3) areas in which consultations may decrease health care value; and (4) an agenda for future research on this topic. Identifying practice variation across providers is a key first step in identifying low-value practices.1 Multiple studies of adult inpatients using Medicare administrative data revealed wide variation in consultation use across hospitals that persist after adjustment for patient …