should we curb the curbside?
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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
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