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
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/RECS
W/ FORMAL
CONSULT
Methods
Denver 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 study
“Consultee”
Hospitalist B – “Official Consultant”
Hospitalist A – “Curbside physician”
Formal Consult
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
25
45%
Number of curbsides
20
15
19%
10
17%
11%
5
8%
0
Psychiatry
ER
Ob/gyn
Neurology
Other
Requesting Provider
30
53%
25
Consults (N)
20
15
10
17%
19%
11%
5
0
Resident
Intern
Attending
Other
Consultative Concern
35
30
**Consults
could be listed
in more than 1
category**
62%
Consults (N)
25
43%
20
15
28%
21%
10
9%
5
0
Treatment
Evaluation
Discharge?
Diagnosis
Lab
Medical Issue
30
57%
Consults (N)
25
49%
20
36%
15
10
19%
17%
13%
5
0
13%
**Consults
could be
listed in more
than 1
category**
Number of Questions Asked
30
55%
25
Consults (N)
20
15
10
28%
17%
5
0
0 to 2
3 to 5
>5
Advice Given
30
55%
25
45%
Consults (N)
20
15
10
5
0
Same Advice
Different Advice
Management Changes
30
60%
3rd Reviewer
29/47 (62%)
Consults (N)
25
20
Major: 10
(36%)
40%
3rd Reviewer
agreed in
24/28 (86%)
15
10
Minor: 18
(64%)
5
0
No change
Change
Curbside Sufficient?
35
30
3rd Reviewer
agreed 17/18
(94%)
62%
Consults (N)
25
38%
20
15
10
5
0
Curbside Sufficient
Curbside Insuffient
Information Accuracy
30
Consults (N)
25
49%
20
51%
Incomplete
& Inaccurate:
5 (21%)
Incorrect:
8 (33%)
15
10
Incomplete:
11 (46%)
5
0
Accurate and Complete
Inaccurate or incomplete
Advice Given
20
18
16
Information
Accurate and
70%
Complete
N=23
Information
Inaccurate or
Incomplete
N=24
79%
Consults (N)
14
P <0.001
12
10
30%
8
21%
6
4
2
0
Same
Different
Same
Different
Management Changes
25
Consults (N)
20
Information
Inaccurate or
Incomplete
N=24
Information
Accurate and
Complete
N=23
74%
92%
Major:
45%
P <0.0001
15
10
26%
Minor:
55%
5
Minor: 100%
Major: 0%
8%
0
Same
Different
Same
Different
Sufficiency of Curbside
25
91%
Consults (N)
20
Information
Accurate and
Complete
N=23
Information
Inaccurate or
Incomplete
N=24
P <0.0001
15
10
67%
33%
5
9%
0
Yes
No
Yes
Curbside Sufficient
No
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
Conclusions
Curbside consults are associated with
considerable RISK that the advice provided
and the resulting management decisions
made are incorrect.
Investigators
Marisha Burden*
Ellen Sarcone*
Angela Keniston
Barbara Statland
Julie Taub
Rebecca Allyn
Mark Reid
Lilia Cervantes
Sarah Stella
*Co-Principal Investigators
Gaby Frank
Nick Scaletta
Smitha Chadaga
Nancy Maller
Margherita Mascolo
Jeff Zoucha
Mary Maher
Rick Albert
Questions?
Marisha.Burden@dhha.org