Assessment of Hospitalist-Subspecialist Agreement About Who Should Be in Charge and Comparison With Actual Assignment Practices

Abstract

BACKGROUND: A key juncture in patient hospitalization is determining which type of physician should be primarily responsible for directing treatment. We (1) examine the frequency hospitalists and subspecialists agree on preferred assignments and (2) compare preferred assignment with actual assignment. METHODS: Using a mixed methods approach, we first surveyed 66 physicians in 8 specialties about hospitalist assignments versus subspecialist assignments for 176 diagnoses at an academic children’s hospital. Agreement was calculated by using the interrater reliability coefficient, Pi. We subsequently compared survey responses to actual hospitalization data from January 2009 to August 2015. RESULTS: Specialty and physician response rates were 100% and 44%, respectively. For preferred assignment among hospitalists and specialists, some diagnoses (eg, gastroesophageal reflux, syncope) experienced high agreement (π = 0.714–1.000); other diagnoses (eg, Guillain-Barre, encephalopathy) had less agreement (π = 0.000–0.600). Hematologists and oncologists agreed among themselves most frequently (73%); endocrinologists agreed among themselves least frequently (9%). Perceptions of agreement were often higher than actual survey results. Of the 25 highest volume diagnoses, 7 were conditions with consensus (Pi ≥ 0.6) about assignment, and of those conditions, 6 were assigned to a subspecialist at least 50% of the time, although consensus indicated a hospitalist should have been assigned (1597 hospitalizations). CONCLUSIONS: This is the first study used to analyze preferences of hospitalist-subspecialist assignment and show variation from actual practice. Although physicians assessed the same patient information, agreement on preferred assignment varied noticeably across diagnoses and subspecialties. With our results, we reveal potential challenges in integrating hospitalists with other specialists and provide evidence for standardizing certain aspects of physician roles.