1. Should We Curb the Curbside? Marisha Burden, MD Chief of Hospital Medicine Denver Health Medical Center Assistant Professor of Medicine University of Colorado School of Medicine

2. Curbside View

3. Formal Evaluation

4. Curbsides

5. Curbsides – Previous Studies Quantity requested Subspecialties consulted Types of questions asked Time spent MD perceptions

6. Curbsides

7. Hypotheses INCOMPLETE INFORMATION DURING CURBSIDE INCORRECT INFORMATION DURING CURBSIDE DIFFERENT ADVICE/RECS W/ FORMAL CONSULT

8. Methods Denver Health Prospective Cohort 1 Year Intermittent 18 Hospitalist Physicians

9. Definitions Consulting provider asked for advice, suggestions, opinions Did not ask hospitalist to see patient Excluded: Administrative, patients already being seen by hospitalist

10. Curbsides – Our study Hospitalist A – “Curbside physician” Formal Consult Hospitalist B – “Official Consultant” “Consultee”

11. Methods Curbside consults neither solicited, discouraged Requesting providers not informed of study or debriefed Analysis: Chi Square

12. Results 215 Study days50 curbside consults3 Formal consults declined47 consults with both curbsides + formal consults

13. Requesting Service 8% 11% 19% 45% 17%

14. Requesting Provider 53% 17% 19% 11%

15. Consultative Concern 43% 28% 62% 21% 9% **Consults could be listed in more than 1 category**

16. Medical Issue 57% 19% 17% 13% 49% 36% **Consults could be listed in more than 1 category**

17. Number of Questions Asked 17% 55% 28%

18. Advice Given 45% 55%

19. Management Changes 40% 60% 3 rd Reviewer 29/47 (62%) 3 rd Reviewer agreed in 24/28 (86%) Minor: 18 (64%) Major: 10 (36%) Consults (N)

20. Curbside Sufficient? 62% 38% 3 rd Reviewer agreed 17/18 (94%)

21. Information Accuracy 49% 51% Incorrect: 8 (33%) Incomplete: 11 (46%) Incomplete & Inaccurate: 5 (21%) Consults (N)

22. Advice Given Information Accurate and Complete N=23 Information Inaccurate or Incomplete N=24 P <0.001 70% 30%

23. Management Changes Information 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% Consults (N)

24. Sufficiency of Curbside Information Accurate and Complete N=23 Information Inaccurate or Incomplete N=24 P <0.0001 91% 9% 33% 67% Curbside Sufficient

25. Examples – Management Changes MINORMAJOR Platelets > 1 million, Tx? Pt w/ stab wound, pericardial window Repeat xray?  Patient septic Chest pain  Purulent OM DiabetesHemorrhoidal bleeding

26. Post Hoc Analysis AssociationNo Association Consulting Service Consulting Provider Medical Issue Number of questions Whether curbside was felt to be sufficient Consult issue

27. Strengths 1 st prospective study 18 Hospitalists Excellent 3 rd Party Agreement Conducted over 1 year

28. Weaknesses Small N (50) Teaching hospital Urban safety net hospital Hawthorne Effect

29. Conclusions Curbside consults are associated with considerable RISK that the advice provided and the resulting management decisions made are incorrect.

30. Investigators Marisha Burden* Ellen Sarcone* Angela Keniston Barbara Statland Julie Taub Rebecca Allyn Mark Reid Lilia Cervantes Sarah Stella Gaby Frank Nick Scaletta Smitha Chadaga Nancy Maller Margherita Mascolo Jeff Zoucha Mary Maher Rick Albert *Co-Principal Investigators

31. Questions? Marisha.Burden@dhha.org