The Impact of Outpatient Laboratory Alerting Mechanisms in Patients with AKI

Background

AKI is an abrupt decrease in kidney function associated with significant morbidity and mortality. Electronic notifications of AKI have been utilized in patients who are hospitalized, but their efficacy in the outpatient setting is unclear.

Methods

We evaluated the effect of two outpatient interventions: an automated comment on increasing creatinine results (intervention I; 6 months; n=159) along with an email to the provider (intervention II; 3 months; n=105), compared with a control (baseline; 6 months; n=176). A comment was generated if a patient's creatinine increased by >0.5 mg/dl (previous creatinine ≤2.0 mg/dl) or by 50% (previous creatinine >2.0 mg/dl) within 180 days. Process measures included documentation of AKI and clinical actions. Clinical outcomes were defined as recovery from AKI within 7 days, prolonged AKI from 8 to 89 days, and progression to CKD with in 120 days.

Results

Providers were more likely to document AKI in interventions I (P=0.004; OR, 2.80; 95% CI, 1.38 to 5.67) and II (P=0.01; OR, 2.66; 95% CI, 1.21 to 5.81). Providers were also more likely to discontinue nephrotoxins in intervention II (P<0.001; OR, 4.88; 95% CI, 2.27 to 10.50). The median time to follow-up creatinine trended shorter among patients with AKI documented (21 versus 42 days; P=0.11). There were no significant differences in clinical outcomes.

Conclusions

An automated comment was associated with improved documented recognition of AKI and the additive intervention of an email alert was associated with increased discontinuation of nephrotoxins, but neither improved clinical outcomes. Translation of these findings into improved outcomes may require corresponding standardization of clinical practice protocols for managing AKI.

Emergency department visits and inpatient hospitalizations among older patients with brain metastases: a dual population- and institution-level analysis

Background

Older patients with brain metastases (BrM) commonly experience symptoms that prompt acute medical evaluation. We characterized emergency department (ED) visits and inpatient hospitalizations in this population.

Methods

We identified 17 789 and 361 Medicare enrollees diagnosed with BrM using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database (2010-2016) and an institutional database (2007-2016), respectively. Predictors of ED visits and hospitalizations were assessed using Poisson regression.

Results

The institutional cohort averaged 3.3 ED visits/1.9 hospitalizations per person-year, with intracranial disease being the most common reason for presentation/admission. SEER-Medicare patients averaged 2.8 ED visits/2.0 hospitalizations per person-year. For patients with synchronous BrM (N = 7834), adjusted risk factors for ED utilization and hospitalization, respectively, included: male sex (rate ratio [RR] = 1.15 [95% CI = 1.09-1.22], P < .001; RR = 1.21 [95% CI = 1.13-1.29], P < .001); African American vs white race (RR = 1.30 [95% CI = 1.18-1.42], P < .001; RR = 1.25 [95% CI = 1.13-1.39], P < .001); unmarried status (RR = 1.07 [95% CI = 1.01-1.14], P = .02; RR = 1.09 [95% CI = 1.02-1.17], P = .01); Charlson comorbidity score >2 (RR = 1.27 [95% CI = 1.17-1.37], P < .001; RR = 1.36 [95% CI = 1.24-1.49], P < .001); and receipt of non-stereotactic vs stereotactic radiation (RR = 1.44 [95% CI = 1.34-1.55, P < .001; RR = 1.49 [95% CI = 1.37-1.62, P < .001). For patients with metachronous BrM (N = 9955), ED visits and hospitalizations were more common after vs before BrM diagnosis (2.6 vs 1.2 ED visits per person-year; 1.8 vs 0.9 hospitalizations per person-year, respectively; RR = 2.24 [95% CI = 2.15-2.33], P < .001; RR = 2.06 [95% CI = 1.98-2.15], P < .001, respectively).

Conclusions

Older patients with BrM commonly receive hospital-level care secondary to intracranial disease, especially in select subpopulations. Enhanced care coordination, closer outpatient follow-up, and patient navigator programs seem warranted for this population.

Provider experience and satisfaction with a novel 'virtual team rounding' program during the COVID-19 pandemic

BACKGROUND

New inpatient virtual care models have proliferated in response to the challenges presented by the coronavirus disease 2019 (COVID-19) pandemic; however, few of these programs have yet been evaluated for acceptability and feasibility.

OBJECTIVE

Assess feasibility and provider experience with the Virtual Team Rounding Program (VTRP), a quality improvement project developed and rapidly scaled at Brigham and Women's Hospital in Boston, MA, in response to the surge of COVID-19 patients in the spring of 2020.

METHODS

We surveyed 777 inpatient providers and 41 providers who served as 'virtual rounders' regarding their experience with the program. Inpatient providers were asked about their overall satisfaction with the program, whether the program saved them time, and if so, how much and their interest in working with a similar program in the future. Providers who had worked as virtual rounders were asked about their overall satisfaction with the program, the overall difficulty of the work and their interest in participating in a similar program in the future.

RESULTS

We find that among both groups the program was well-received, with 72.5% of inpatient providers and 85.7% of virtual rounders reporting that they were 'satisfied' or 'very satisfied' with their experience with the program. Among inpatient providers who worked with the program, two-thirds reported the program saved them time on a daily basis. Inpatient respondents who had worked with virtual rounders were more likely to say that they would be interested in working with the VTRP in the future compared with respondents who never worked with a virtual rounder (75.3 vs 52.5%, P < 0.001).

CONCLUSION

As the pandemic continues, rapidly implementing and studying virtual care delivery programs is crucial for hospitals and health systems. We demonstrate the feasibility and acceptability of a 'virtual rounding' program assisting inpatient providers. Future work should examine the impact of these programs on patient outcomes.

Nephrologist Performance in the Merit-Based Incentive Payment System

RATIONALE & OBJECTIVE

The Merit-Based Incentive Payment System (MIPS) is the largest quality payment program administered by the Centers for Medicare & Medicaid Services. Little is known about predictors of nephrologist performance in MIPS.

STUDY DESIGN

Cross-sectional analysis.

SETTING & PARTICIPANTS

Nephrologists participating in MIPS in performance year 2018.

PREDICTORS

Nephrologist characteristics: (1) participation type (individual, group, or MIPS alternative payment model [APM]), (2) practice size, (3) practice setting (rural, Health Professional Shortage Area [HPSA], or hospital based), and (4) geography (Census Division).

OUTCOMES

MIPS Final, Quality, Promoting Interoperability, Improvement Activities, and Cost scores. Using published consensus ratings, we also examined the validity of MIPS Quality measures selected by nephrologists.

ANALYTICAL APPROACH

Unadjusted and multivariable-adjusted linear regression models assessing the associations between nephrologist characteristics and MIPS Final scores.

RESULTS

Among 6,117 nephrologists participating in MIPS in 2018, the median MIPS Final score was 100 (interquartile range, 94-100). In multivariable-adjusted analyses, MIPS APM participation was associated with a 12.5-point (95% CI, 10.6-14.4) higher score compared with individual participation. Nephrologists in large (355-4,294 members) and medium (15-354 members) practices scored higher than those in small practices (1-14 members). In analyses adjusted for practice size, practice setting, and geography, among individual and group participants, HPSA nephrologists scored 1.9 (95% CI, -3.6 to -0.1) points lower than non-HPSA nephrologists, and hospital-based nephrologists scored 6.0 (95% CI, -8.3 to -3.7) points lower than non-hospital-based nephrologists. The most frequently reported quality measures by individual and group participants had medium to high validity and were relevant to nephrology care, whereas MIPS APM measures had little relevance to nephrology.

LIMITATIONS

Lack of adjustment for patient characteristics.

CONCLUSIONS

MIPS APM participation, larger practice size, non-HPSA setting, and non-hospital-based setting were associated with higher MIPS scores among nephrologists. Our results inform strategies to improve MIPS program design and generate meaningful distinctions between practices that will drive improvements in care.

Hypocalcemia is associated with hypotension during CRRT: A secondary analysis of the Acute Renal Failure Trial Network Study

PURPOSE

We investigated the effect of potentially modifiable continuous renal replacement therapy (CRRT)-related treatment factors on the risk of severe hypotension.

MATERIALS AND METHODS

We carried out a secondary statistical analysis of the Acute Renal Failure Trial Network (ATN) trial. The primary exposures of interest were CRRT treatment dose, ultrafiltration rate, blood flow rate, ionized calcium level and type of anti-coagulation used. The primary outcome was severe hypotension, defined as vasopressor-inotropic score > 18 and calculated based on treatment doses of vasopressor and inotropic agents.

RESULTS

Of 1124 individuals enrolled in the ATN Trial, 786 were managed with CRRT. 265/786 (33.7%) patients experienced severe hypotension during the trial. A serum ionized calcium <1.02 mmol/l was associated with a higher risk of severe hypotension compared to a serum calcium >1.02 mmol/l (hazard ratio 2.9; 95% CI 1.5-5.7). There was no significant difference in the risk of hypotension associated with other CRRT treatment factors.

CONCLUSIONS

Of the CRRT treatment factors studied, hypocalcemia with a serum ionized calcium <1.02 mmol/l was associated with a significantly increased risk of treatment-associated hypotension. Further studies will be required to assess whether treatment targets for serum calcium improve the risk of hypotension during CRRT.

Reassessing the Inclusion of Race in Diagnosing Kidney Diseases: An Interim Report From the NKF-ASN Task Force

For almost 2 decades, equations that use serum creatinine, age, sex, and race to estimate glomerular filtration rate (GFR) have included "race" as Black or non-Black. Given considerable evidence of disparities in health and health care delivery in African American communities, some regard keeping a race term in GFR equations as a practice that differentially influences access to care and kidney transplantation. Others assert that race captures important non-GFR determinants of serum creatinine and its removal from the calculation may perpetuate other disparities. The National Kidney Foundation (NKF) and American Society of Nephrology (ASN) established a task force in 2020 to reassess the inclusion of race in the estimation of GFR in the United States and its implications for diagnosis and subsequent management of patients with, or at risk for, kidney diseases. This interim report details the process, initial assessment of evidence, and values defined regarding the use of race to estimate GFR. We organized activities in phases: (1) clarify the problem and examine evidence, (2) evaluate different approaches to address use of race in GFR estimation, and (3) make recommendations. In phase 1, we constructed statements about the evidence and defined values regarding equity and disparities; race and racism; GFR measurement, estimation, and equation performance; laboratory standardization; and patient perspectives. We also identified several approaches to estimate GFR and a set of attributes to evaluate these approaches. Building on evidence and values, the attributes of alternative approaches to estimate GFR will be evaluated in the next phases and recommendations will be made.

Expanding Utilization of Home Dialysis: An Action Agenda From the First International Home Dialysis Roundtable

In a groundbreaking meeting, leading global kidney disease organizations came together in the fall of 2020 as an International Home Dialysis Roundtable (IHDR) to address strategies to increase access to and uptake of home dialysis, both peritoneal dialysis and home hemodialysis. This challenge has become urgent in the wake of the coronavirus disease 2019 (COVID-19) pandemic, during which patients with advanced kidney disease, who are more susceptible to viral infections and severe complications, must be able to safely physically distance at home. To boost access to home dialysis on a global scale, IHDR members committed to collaborate, through the COVID-19 public health emergency and beyond, to promote uptake of home dialysis on a broad scale. Their commitments included increasing the reach and influence of key stakeholders with policy makers, building a cooperative of advocates and champions for home dialysis, working together to increase patient engagement and empowerment, and sharing intelligence about policy, education, and other programs so that such efforts can be operationalized globally. In the spirit of international cooperation, IHDR members agreed to document, amplify, and replicate established efforts shown to improve access to home dialysis and support new policies that facilitate access through procedures, innovation, and reimbursement.

Peter WL, Warfield C, Powe NR. Reassessing the Inclusion of Race in Diagnosing Kidney Diseases: An Interim Report from the NKF-ASN Task Force

For almost two decades, equations that use serum creatinine, age, sex, and race to eGFR have included "race" as Black or non-Black. Given considerable evidence of disparities in health and healthcare delivery in African American communities, some regard keeping a race term in GFR equations as a practice that differentially influences access to care and kidney transplantation. Others assert that race captures important non GFR determinants of serum creatinine and its removal from the calculation may perpetuate other disparities. The National Kidney Foundation (NKF) and American Society of Nephrology (ASN) established a task force in 2020 to reassess the inclusion of race in the estimation of GFR in the United States and its implications for diagnosis and subsequent management of patients with, or at risk for, kidney diseases. This interim report details the process, initial assessment of evidence, and values defined regarding the use of race to estimate GFR. We organized activities in phases: (1) clarify the problem and examine evidence, (2) evaluate different approaches to address use of race in GFR estimation, and (3) make recommendations. In phase one, we constructed statements about the evidence and defined values regarding equity and disparities; race and racism; GFR measurement, estimation, and equation performance; laboratory standardization; and patient perspectives. We also identified several approaches to estimate GFR and a set of attributes to evaluate these approaches. Building on evidence and values, the attributes of alternative approaches to estimate GFR will be evaluated in the next phases and recommendations will be made.

Funding Innovative Dialysis Technology in the United States: Home Dialysis and the ESRD Transitional Add-on Payment for New and Innovative Equipment and Supplies (TPNIES)

Innovative, patient-centered, and pragmatic dialysis technologies are urgently needed to accommodate the growing national interest in home dialysis use. To help achieve this goal, the US Centers for Medicare & Medicaid Services (CMS) are expanding reimbursement for eligible home dialysis machines through an existing payment mechanism, the transitional add-on payment for new and innovative equipment and supplies (TPNIES). This mechanism incentivizes the early adoption of innovative equipment into practice by reimbursing dialysis providers up to 26% of the total cost of approved home dialysis machines. Machines are evaluated for TPNIES eligibility using prespecified substantial clinical improvement (SCI) criteria that are derived from the Inpatient Prospective Payment System (for non-nephrology technologies). Although the SCI criteria may be suitable for some non-nephrology technologies, they have not been adapted to consider the unique and complex care inherent in home dialysis. Thus, many of the SCI criteria appear unsuitable for home dialysis machines. To better incentivize innovation, CMS should develop nephrology-specific transparent and pragmatic criteria for TPNIES. In this perspective, we provide an overview of the TPNIES payment mechanism, highlight areas of concern within the policy, and offer solutions for improving TPNIES that could better promote the adoption of new home dialysis machines.

Perioperative Code Status Discussions: How Are We Doing?

Approximately 15% of patients with a code status of do-not-resuscitate (DNR) or do-not-intubate (DNI) present for surgery. Despite professional guidelines requiring discussions with patients regarding perioperative resuscitation, it is unclear whether these recommendations are consistently followed. Our review of 158 patient encounters with established DNR/DNI code status found that code status discussions (CSDs) were documented only 70% of the time, and code status orders were inconsistently entered to reflect those discussions. We present solutions to improve CSD documentation, including refining perioperative workflows, simplifying code status choices, optimizing electronic health record order entry, and a supplementary consent form to facilitate code status review.

The essential role of population health during and beyond COVID-19

The coronavirus disease 2019 (COVID-19) pandemic has fundamentally changed how health care systems deliver services and revealed the tenuousness of care delivery based on face-to-face office visits and fee-for-service reimbursement models. Robust population health management, fostered by value-based contract participation, integrates analytics and agile clinical programs and is adaptable to optimize outcomes and reduce risk during population-level crises. In this article, we describe how mature population health programs in a learning health system have been rapidly leveraged to address the challenges of the pandemic. Population-level data and care management have facilitated identification of demographic-based disparities and community outreach. Telemedicine and integrated behavioral health have ensured critical primary care and specialty access, and mobile health and postacute interventions have shifted site of care and optimized hospital utilization. Beyond the pandemic, population health can lead as a cornerstone of a resilient health system, better prepared to improve public health and mitigate risk in a value-based paradigm.

Examining the Potential Impact of Race Multiplier Utilization in Estimated Glomerular Filtration Rate Calculation on African-American Care Outcomes

BACKGROUND

Advancing health equity entails reducing disparities in care. African-American patients with chronic kidney disease (CKD) have poorer outcomes, including dialysis access placement and transplantation. Estimated glomerular filtration rate (eGFR) equations, which assign higher eGFR values to African-American patients, may be a mechanism for inequitable outcomes. Electronic health record-based registries enable population-based examination of care across racial groups.

OBJECTIVE

To examine the impact of the race multiplier for African-Americans in the CKD-EPI eGFR equation on CKD classification and care delivery.

DESIGN

Cross-sectional study SETTING: Two large academic medical centers and affiliated community primary care and specialty practices.

PARTICIPANTS

A total of 56,845 patients in the Partners HealthCare System CKD registry in June 2019, among whom 2225 (3.9%) were African-American.

MEASUREMENTS

Exposures included race, age, sex, comorbidities, and eGFR. Outcomes were transplant referral and dialysis access placement.

RESULTS

Of 2225 African-American patients, 743 (33.4%) would hypothetically be reclassified to a more severe CKD stage if the race multiplier were removed from the CKD-EPI equation. Similarly, 167 of 687 (24.3%) would be reclassified from stage 3B to stage 4. Finally, 64 of 2069 patients (3.1%) would be reassigned from eGFR > 20 ml/min/1.73 m2 to eGFR ≤ 20 ml/min/1.73 m2, meeting the criterion for accumulating kidney transplant priority. Zero of 64 African-American patients with an eGFR ≤ 20 ml/min/1.73 m2 after the race multiplier was removed were referred, evaluated, or waitlisted for kidney transplant, compared to 19.2% of African-American patients with eGFR ≤ 20 ml/min/1.73 m2 with the default CKD-EPI equation.

LIMITATIONS

Single healthcare system in the Northeastern United States and relatively small African-American patient cohort may limit generalizability.

CONCLUSIONS

Our study reveals a meaningful impact of race-adjusted eGFR on the care provided to the African-American CKD patient population.

Improving hepatitis B vaccination rates for advanced chronic kidney disease patients: a quality improvement initiative

Introduction

Chronic kidney disease (CKD) patients are vulnerable to hepatitis B, and immunization prior to end stage kidney disease is recommended to optimize seroconversion. Our institution undertook a process improvement approach to increase hepatitis B vaccination in stage 4 and 5 CKD patients.

Methods

Four strategies were utilized such as: (1) Electronic health record (EHR)-based CKD registry to identify patients, (2) EHR-based physician/nurse reminders, (3) a co-located nurse appointment for vaccine administration, and (4) information sharing and provider awareness effort. The CKD registry was utilized to identify patients with stage 4 or 5 CKD, with at least two clinic visits in the prior 2 years, who had not received the hepatitis B vaccine or did not have serologic evidence of immunity. Target monthly vaccination rate was set at 75%, based on clinic leadership, nephrologist, and nurse consensus.

Results

A total of 239 patients were included in the study period, from November 2018 to January 2019 (observation period) and from February 2019 to September 2019 (intervention period). Monthly vaccination rate improved from 48% in November 2018 to the target rate of 75% by the end of the intervention (August and September 2019). There was a statistically significant increase from the rate of vaccination at a unique patient level in the first month of the baseline period, compared to the last month of the intervention period (51 vs. 75% p = 0.03).

Conclusions

Utilizing a nurse-led approach to hepatitis B vaccination, coupled with EHR-based tools, along with continuous monitoring of performance, helped to improve hepatitis B vaccination among CKD stage 4 and 5 patients.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10157-020-02013-4.

Palliative Care in the Advancing American Kidney Health Initiative: A Call for Inclusion in Kidney Care Delivery Models

The Advancing American Kidney Health (AAKH) Initiative aims to promote high-value patient-centered care by improving access to and quality of treatment options for kidney failure. The 3 explicit goals of the initiative are to reduce the incidence of kidney failure, increase the number of available kidneys for transplantation, and increase transplantation and home dialysis. To ensure a patient-centered movement toward home dialysis modalities, actionable principles of palliative care, including systematic communication and customized treatment plans, should be incorporated into this policy. In this perspective, we describe 2 opportunities to strengthen the patience-centeredness of the AAKH Initiative through palliative care: (1) serious illness conversations should be required for all dialysis initiations in the End-Stage Renal Disease Treatment Choices model, and (2) conservative kidney management should be counted as a home modality alongside peritoneal dialysis and home hemodialysis. A serious illness conversation can help clinicians discern whether a patient’s goals and values are best respected by a home dialysis modality or whether a nondialytic strategy such as conservative kidney management should be considered. An intensive and careful patient- and family-centered selection process will be necessary to ensure that no patient is pressured to forego conventional dialysis.

Estimating Shortages in Capacity to Deliver Continuous Kidney Replacement Therapy During the COVID-19 Pandemic in the United States

RATIONALE & OBJECTIVE

During the coronavirus disease 2019 (COVID-19) pandemic, New York encountered shortages in continuous kidney replacement therapy (CKRT) capacity for critically ill patients with acute kidney injury stage 3 requiring dialysis. To inform planning for current and future crises, we estimated CKRT demand and capacity during the initial wave of the US COVID-19 pandemic.

STUDY DESIGN

We developed mathematical models to project nationwide and statewide CKRT demand and capacity. Data sources included the Institute for Health Metrics and Evaluation model, the Harvard Global Health Institute model, and published literature.

SETTING & POPULATION

US patients hospitalized during the initial wave of the COVID-19 pandemic (February 6, 2020, to August 4, 2020).

INTERVENTION

CKRT.

OUTCOMES

CKRT demand and capacity at peak resource use; number of states projected to encounter CKRT shortages.

MODEL, PERSPECTIVE, & TIMEFRAME

Health sector perspective with a 6-month time horizon.

RESULTS

Under base-case model assumptions, there was a nationwide CKRT capacity of 7,032 machines, an estimated shortage of 1,088 (95% uncertainty interval, 910-1,568) machines, and shortages in 6 states at peak resource use. In sensitivity analyses, varying assumptions around: (1) the number of pre-COVID-19 surplus CKRT machines available and (2) the incidence of acute kidney injury stage 3 requiring dialysis requiring CKRT among hospitalized patients with COVID-19 resulted in projected shortages in 3 to 8 states (933-1,282 machines) and 4 to 8 states (945-1,723 machines), respectively. In the best- and worst-case scenarios, there were shortages in 3 and 26 states (614 and 4,540 machines).

LIMITATIONS

Parameter estimates are influenced by assumptions made in the absence of published data for CKRT capacity and by the Institute for Health Metrics and Evaluation model's limitations.

CONCLUSIONS

Several US states are projected to encounter CKRT shortages during the COVID-19 pandemic. These findings, although based on limited data for CKRT demand and capacity, suggest there being value during health care crises such as the COVID-19 pandemic in establishing an inpatient kidney replacement therapy national registry and maintaining a national stockpile of CKRT equipment.

Health Policy and Kidney Care in the United States: Core Curriculum 2020

Kidney care in the United States is highly regulated, reflecting the dominance of Medicare as the primary payer for dialysis since inclusion of the end-stage renal disease (ESRD) benefit into payment policy in 1973. In the ensuing decades, bundled payments have been introduced for dialysis and quality programs have been adopted for both ESRD and nondialysis chronic kidney disease care. In this installment of the Core Curriculum in Nephrology, we review the key laws and regulations affecting kidney care in the United States, the Medicare ESRD program, quality assessment and pay-for-performance programs including the ESRD Quality Incentive Program, incentives and disincentives for specific kidney failure care modalities, and recent landmark initiatives to promote more coordinated kidney care across the spectrum of kidney disease. Additional discussion covers policies guiding the care of undocumented immigrants and provision of hospice and palliative care to people with kidney failure. Last, we discuss how the kidney community can activate to advocate effectively to promote better kidney care in the United States.

Utility, Appropriateness, and Content of Electronic Consultations Across Medical Subspecialties

BACKGROUND

Electronic consultations (e-consults) can facilitate patient access to specialists, minimize travel, and reduce unnecessary in-person visits. However, metrics to enable study of e-consults and their effect on processes and patient care are lacking.

OBJECTIVE

To assess novel metrics of e-consult appropriateness and utility.

DESIGN

Retrospective cohort study.

SETTING

Primary and specialty care practices at 2 large academic and 2 community hospitals of an integrated health system.

PARTICIPANTS

Patients with e-consult requests to 5 specialties-hematology, infectious disease, dermatology, rheumatology, and psychiatry-between October 2017 and November 2018.

MEASUREMENTS

The appropriateness of e-consult inquiries was assessed by review of medical records and defined as meeting the following 4 criteria: not answerable by reviewing evidence-based summary sources ("point-of-care resource test"), not merely requesting logistic information, having appropriate clinical urgency, and having appropriate patient complexity. Interrater agreement in assessments of e-consult appropriateness was assessed by the κ statistic. Utility of e-consults was assessed by the rate of avoided visits (AVs), defined by the absence of an in-person visit to the same specialty within 120 days.

RESULTS

Overall, 6512 eligible e-consults were made by 1096 referring providers to 121 specialist consultants. Inquiries were characterized as diagnostic, therapeutic, for provider education, or at the request of the patient. Most consultations were answered within 1 day, with variation across specialties (73.1% for psychiatry to 87.8% for infectious disease). Overall, 70.2% of e-consults met all 4 criteria for appropriateness; the frequency of unmet criteria varied among specialties. Raters agreed on the appropriateness of 94% of e-consults (κ = 0.57 [95% CI, 0.36 to 0.79]), indicating moderate agreement. The overall rate of AVs across the 5 specialties was 81.2%; the highest rate was in psychiatry (92.6%) and the lowest in dermatology (61.9%).

LIMITATION

Generalizability is unknown outside a single integrated health system, where requesting and consulting providers share a common electronic health record.

CONCLUSION

Novel metrics to assess the appropriateness and utility of e-consults provide meaningful insight into practice, provide a rubric for comparison in future studies in additional settings, and suggest areas to improve resource use and patient care.

PRIMARY FUNDING SOURCE

None.