Preconsultation Exchange in the United States: Use, Awareness, and Attitudes

ABSTRACT

Objectives

Demand for specialty care exceeds supply in many healthcare systems in the United States. Preconsultation exchange has the potential to increase access to specialty care, and increase its timeliness and efficiency, by triaging need and urgency and streamlining the previsit workup. We sought to characterize attitudes toward, use of, and concerns regarding preconsultation exchange among US internists.

Study Design

Prospective cross-sectional survey.

Methods

We administered a Web-based survey to a large national panel of US internists maintained by the American College of Physicians.

Results

Response rate was 55% (N = 451) with minimal differences between responders and nonresponders. Of responders, only 13% were initially familiar with the term “preconsultation exchange,” but once defined, 28% were classified as frequent users, 40% as occasional users, and 32% as rare/never users. Internists used preconsultation exchange to: guide the prespecialty visit workup (78%), answer clinical questions without a patient visit to the specialist (71%), triage referral urgency (67%), and transfer referrals to a more appropriate specialty (47%). Responders supported multiple benefits of preconsultation exchange, but also reported concerns regarding reimbursement, liability, physicians taking personal responsibility for patient care, and inadequate exchange of clinical information. Compared with primary care physicians, specialists recognized more benefits of preconsultation exchange, but also expressed more concerns. The majority of responders reported increased willingness to use preconsultation exchange if specific remedies were applied.

Conclusions

Most US internists participate in preconsultation exchange and agree with its potential benefits. However, important concerns and barriers exist. Methods to reduce barriers to preconsultation exchange should be identified.

Am J Manag Care. 2014;20(12):e556-e564

Preconsultation exchange can improve access to, and timeliness and efficiency of, specialty care, particularly in resource-constrained settings. We surveyed a national panel of practicing internists in the United States to assess attitudes toward, and use of, preconsultation exchange.

• Only 13% of responders were familiar with the term “preconsultation exchange,” but once defined, 68% reported at least occasional use.
• Responders supported multiple benefits of preconsultation exchange.
• Specialists recognized more benefits of preconsultation exchange than did primary care physicians, but also reported more concerns.
• Survey responders reported increased likelihood of using preconsultation exchange in the setting of specific remedies.

Demand for specialty care in the United States continues to rise, with the past decade witnessing a 150% increase in ambulatory specialty care referrals.¹ Demand may increase further as millions of Americans become newly insured through healthcare reform.^2,3 Despite high demand, specialty care remains among the most limited of medical resources, particularly in resource-constrained settings such as the healthcare safety net.⁴ “Preconsultation exchange” (PCE) may reduce this supplydemand mismatch by increasing access to, and efficiency of, specialty care.⁵

Described by the American College of Physicians (ACP) in 2010, PCE is a clinical interaction between a primary care provider and a specialist that occurs prior to, or in lieu of, an in-person ambulatory specialty care evaluation.⁵ Although PCE applies to the well-established concept of “curbside consultation” (in which a physician provides informal advice to another physician without personally evaluating a patient),^6,7 it covers additional functions, including: determining need for formal specialty consultation, answering a clinical question without an in-person visit to the specialist, providing guidance to ensure a thorough prespecialty visit workup, triaging urgency of referrals, and redirecting referrals to a more appropriate specialty.⁵ PCE can facilitate provision of specialty care without a formal in-person visit,^8,9 thereby increasing access to specialty care. For patients requiring inperson specialty evaluation, PCE can be used to streamline the prespecialty visit workup, subsequently increasing the efficiency of specialty care.

Research describing PCE remains limited.^8-10 Because formal application of PCE may increase in use in the setting of healthcare reform,¹¹ physicians’ attitudes and concerns should be understood. We designed a survey-based study among a large cohort of internists with several specific aims. We sought to characterize internists’ overall awareness and use of PCE, and to identify personal and practice characteristics associated with frequency of PCE use; we also sought to characterize perceived benefits of, and concerns related to, PCE. Because PCE is a form of specialty care, we hypothesized that primary care and specialty physicians would perceive different benefits and concerns/barriers, so we specifically compared benefits and barriers between these 2 groups.

METHODS

Study Design and Survey Population

We performed a cross-sectional survey among a large national panel of internists in the United States. Initiated in 2011, the Internal Medicine Insider Research Panel is a community of ACP members who participate in research surveys distributed by the ACP Research Center. The panel includes internists practicing both primary and specialty care, but does not include noninternist physicians (eg, family medicine specialists, surgeons, neurologists, and psychiatrists). One percent of ACP members (including trainees) are invited to participate via stratified randomization to ensure generalizability to ACP membership. Members who complete surveys are awarded credit toward Amazon.com gift cards.

The target population was internists providing direct ambulatory patient care (including both primary care and specialty care physicians). Of the 1012 panel members, 828 provided direct ambulatory patient care and were eligible to participate.

Survey Development and Distribution

An existing validated instrument was not available. Our instrument was initially developed by 2 authors (JS, KT), using for reference prior ACP survey questions, the ACP position paper on the patient-centered medical home and PCE,⁵ and discussions with health services research faculty at the University of California, San Francisco. Multiple survey iterations were reviewed, tested, and edited for content validity by all authors and by the aforementioned faculty.

Survey questions addressed: demographics; personal characteristics; professional and practice characteristics; familiarity with and use of PCE; and perceived benefits of, concerns about, and barriers to PCE. Regarding the latter data, subjects were asked to rate their agreement with 6 statements describing potential concerns or barriers to using PCE. Subjects indicating agreement with each concern/barrier statement were given a specific remedy and were asked whether that specific remedy would increase their likelihood of using PCE. These concern/barrier statements and proposed remedies were conceptualized and edited for content validity during the instrument development process described above.

eAppendix

On May 6, 2013, panel members were sent the survey invitation by e-mail with a Web link to the survey, which was administered online using the EFS Panel Program (QuestBack USA, Bridgeport, Connecticut). The survey remained open for 2 weeks, and 3 reminder e-mails were sent to nonresponders—responders were awarded $10 in Amazon.com gift credit. A completed survey was defined a priori as answering the question describing use of PCE (survey question 11, , available at www.ajmc.com).

Data Management and Analysis

Proportions and means were calculated to summarize data; few data were missing (these are reported in footnotes at the end of tables).

To quantify use of PCE, subjects were asked, “How often, if ever, do you participate in preconsultation exchange as either the referring primary care provider or the receiving specialist?” (PCE was defined at the top of survey section 3, eAppendix.) Subjects responded using a 5-point Likert scale including options “always,” “often,” “sometimes,” “rarely,” and “never.” Three pre-specified groups were used for comparative analyses: “frequent users” (“always” or “often” used PCE), “occasional users” (“sometimes” used PCE), and “rare/never users” (“rarely” or “never” used PCE).

We asked subjects to self-identify as a primary care physician or specialty physician. For the purposes of this study, we conceptualized primary/specialty care status as being primarily related to their referral practices. Specifically, we defined primary care physicians as more often making referrals to other providers, and specialty physicians as more often receiving referrals from other providgeners (survey question 6, eAppendix). We used this method because, given the heterogeneity of physicians’ practices even within a single specialty, their primary area of training might not represent their referral practices and could therefore result in misclassification. For example, physicians trained in certain “specialty” areas (such as geriatrics) might consider themselves primary rather than specialty care physicians.

Categorical variables were compared with χ2 tests. Continuous variables were compared using ANOVA and/or 2-tailed t tests. P <.05 was the threshold used for statistical significance. Statistical analyses were performed using SPSS version 21 (IBM, Armonk, New York) and Stata version 11 (StataCorp, College Station, Texas).

Ethical Review

The Institutional Review Board of the University of California, San Francisco, reviewed this study and granted it exempt status.

RESULTS

Response Characteristics

eAppendix Table 1

eAppendix Table 2

Of 828 eligible panel members, 451 (54.5%) completed the survey. Of these, 313 (69.4%) classified themselves as primary care physicians and 138 (30.6%) as specialty physicians. Diverse “primary areas of focus” were represented (). The 451 survey responders did not differ from the 377 nonresponders in age, level of training, or primary versus specialty care (). Responders were 7% less likely than nonresponders to work in private practice (P = .04), but private practice was the most common setting for responders and nonresponders alike.

Awareness and Use of PCE

Only 58 (12.9%) of 451 survey responders were familiar with the term “preconsultation exchange,” with no differences between primary care and specialty physicians (P =.82). However, when this term was subsequently defined (survey question 11, Supplemental Figure), many reported using PCE. Of responders, 127 (28.2%) could be classified as frequent users, 178 (39.5%) as occasional users, and 146 (32.4%) as rare/never users.

Table 1

Some personal and practice characteristics differed among frequent, occasional, and rare/never PCE users. Rare/never users reported fewer years in practice than occasional or frequent users, and frequent users were more likely to work in a health maintenance organization than occasional or rare/never users (). PCE use was similar among primary care physicians and specialists. Frequent users of PCE were more likely to utilize electronic communication with other providers and with patients. However, only 4% of physicians received protected time for such electronic communication.

Uses of PCE

Table 2

Responders reported using multiple functions of PCE (Table 2), most commonly: guiding the previsit workup to prepare the patient for specialty assessment (314, 78.3%); addressing a clinical question without a formal visit to the specialist (283, 70.6%); and triaging the urgency of referred patients (268, 66.8%). Telephone (349, 87%) and electronic health record (186, 46.4%) were the most common mediums used for PCE ().

Among the 50 responders who never used PCE, 36 (72%) indicated this was due to lack of availability. Of those, 17 (47.2%) would definitely or probably use PCE if it were available to them (Table 2).

PCE Benefits

Table 3

A majority of responders agreed with 6 of the 9 proposed benefits of PCE, and more than 40% agreed with the other 3. Specialists were more likely than primary care physicians to agree with 5 of the 9 proposed benefits of PCE ().

PCE Concerns/Barriers and Remedies

Table 4

Subjects were asked to rate their agreement with 6 specific statements describing proposed concerns or barriers related to PCE (). Of responders, 337 (74.7%) agreed financial reimbursement for PCE might be inadequate; 317 (70.3%) agreed physicians should take personal responsibility for all patients referred to them; 208 (46.1%) agreed exchange of clinical information using PCE might be inadequate; 207 (45.9)% agreed there was not enough time in their day to participate in PCE; 189 (41.9%) agreed PCE may pose significant liability risks; and 139 (30.8)% agreed their medical record would not facilitate PCE.

Different concerns were expressed by primary care and specialty care physicians. Nearly twice as many specialists were concerned about liability related to PCE compared with primary care physicians. Specialists also expressed greater concerns regarding financial reimbursement, inadequate exchange of clinical information, and adequacy of the medical record (Table 4).

Subjects indicating agreement with each concern/barrier statement were given a specific proposed remedy and were asked whether that particular remedy would increase their likelihood of using PCE (Table 4). In general, responders reported increased likelihood of using PCE for all the proposed remedies. Primary care physicians were slightly more likely to report increased likelihood of use than specialist physicians for 2 of the 6 remedies.

Compared with attending physicians, residents and fellows (who were included in our study population) may have more ready access to instructors and other sources of specialty advice, and may therefore perceive barriers and potential remedies differently than attending physicians. To investigate this possibility, we performed a sensitivity analysis for the data in Table 4, excluding residents and fellows. The sensitivity analysis showed that relative rankings of importance for barriers/concerns, and specific remedies, changed very little compared with the original analysis. Barriers 3 and 4 traded places in order of importance, and there were no differences in the relative levels of agreement with specific remedies. Additionally, comparisons between primary and specialty care physicians remained stable in the sensitivity analysis.

DISCUSSION

In this survey of a large national cohort of internists providing ambulatory medical care in the United States, only 13% indicated familiarity with the term “preconsultation exchange.” However, 67% reported at least occasional use of PCE, and 28% reported frequent use. Nearly half of those never using PCE indicated willingness to do so if PCE were available. PCE was most often used to guide the pre-visit workup, to answer a clinical question, and to triage urgency. Barriers to using PCE were reported, but there was increased willingness to use PCE if barriers were addressed. Our findings illuminate several important issues related to current and future use of PCE.

One function of PCE is to provide specialty advice in lieu of a formal specialty clinic appointment. This bears similarity to the long-standing practice of “curbside consultation,” in which a physician uses informal advice from a colleague to guide medical care.^6,7 In 1998, primary care and specialist physicians alike reported participating in curbside consultations⁶—16 years later, some themes remain true, particularly the informality of PCE. Four of the 6 primary concerns (personal responsibility, exchange of information, liability, adequacy of medical record) were closely related to the informality of PCE. Specialists were particularly concerned regarding liability related to PCE (though the courts historically have not found fault with specialists providing informal consultations¹²). A large proportion of responders indicated increased willingness to use PCE if these concerns related to informality were addressed. The safety and quality of medical care has improved through formalization of other, previously less formal practices, such as patient “hand-offs,”¹³ hospital discharge,¹⁴ and surgical time-outs.¹⁵ Formalizing the PCE process may increase its acceptance, use, and safety. Such formalization has proved successful in some settings⁸ (as discussed further below), though unintended consequences, such as patient safety risks, must be carefully guarded against.¹⁰

Compared with primary care physicians, specialists supported more benefits of PCE (Table 3). At the same time, specialists expressed more concerns and decreased likelihood of increasing PCE use in the context of specific remedies (Table 4). However, specialists did not differ from primary care physicians in current use of PCE. These findings appear to support one of our guiding principles, which is that PCE is in essence a form of specialty care. Accordingly, our data suggest that while specialists see PCE as a tool for providing specialty care, they perceive increased burden from its use, particularly related to liability and time spent without guaranteed reimbursement. For PCE to increase in use, the relative roles and responsibilities of primary care and specialty physicians will need to be better defined and articulated within individual healthcare systems.

PCE may be increasingly useful in the setting of healthcare reform. At the center of the Patient Protection and Affordable Care Act is a mandate to expand health insurance coverage for 25 million Americans.^2,3 Healthcare systems may face substantial challenges providing medical care to their newly expanded patient populations. While attention has been focused on the ability of the primary care workforce to handle this increased patient load,¹⁶ the supply-demand mismatch for specialty care may also be exacerbated, particularly in the healthcare safety net and other resource-constrained settings.¹⁷ PCE stands to improve this mismatch, as it can increase availability of specialty care. For example, Chen et al recently reported on “eReferral,” which facilitates PCE in San Francisco’s healthcare safety net.⁸ Within 1 year of implementation, the mean waiting time for a routine specialty care appointment dropped from 112 days to 49 days, representing increased access to specialty care. Referrals without a clear consultative question also dropped substantially,¹⁸ helping determine need for formal consultation and better preparing patients for specialty clinic visits. Formalization of the PCE process within the San Francisco healthcare safety net has been well accepted by primary care physicians and specialists alike,¹⁹ and its now-universal use for ambulatory specialty referral has realized many benefits of PCE supported by our survey responders.

Primary and specialty care physicians alike were most concerned that reimbursement for PCE could be inadequate. The dominant fee-for-service environment may provide disincentives to physicians’ participation in patient care outside the context of a billable encounter. In a recent national survey, less than 10% of physicians supported elimination of fee-for-service payment models as a method of cost containment.²⁰ However, healthcare reform will continue to expand the proportion of physicians who operate under global payment systems¹¹ through such models as accountable care organizations and bundled payment strategies.^21-23 As discussed in a recent commentary, specialists and primary care physicians alike should be motivated to redesign practice and payment structures to better coordinate care, reduce inefficiencies, and minimize unnecessary care.¹¹ The authors specifically suggest that specialty care will need to be less reliant on in-person encounters, and that asynchronous Web-based interactions will be of increasing utility and importance.¹¹ Expansion of such models will be highly dependent on payment, and payment models for non—visit-based care will need to be developed and tested. Within the fee-for-service environment, the recently developed “interprofessional consultation” Current Procedural Terminology (CPT) codes may enable physicians to bill for time spent in PCE.

Although PCE has potential benefits for healthcare systems, there are potential negative consequences as well, which were not addressed in our study. A primary potential negative consequence would be overuse of PCE, which could paradoxically result in increased expenditures for specialty care. This could potentially be seen within formalized PCE systems, where physicians have ready access to PCE. The likelihood of such overuse would depend heavily on healthcare systems’ construction of PCE systems, and whether/how participation in PCE is compensated. In San Francisco General Hospital’s eReferral system, participation in PCE is compulsory for referral to specialty care, and neither referring nor reviewing providers are compensated in a fee-for-service manner. Referring providers are required to use eReferral for specialty referral, which is considered part of their overall service to the patient. The amount of time and effort required on the part of primary care providers has been well accepted.¹⁹ Reviewing specialists are salaried university faculty who are allotted a particular fraction of their clinical effort for reviewing and responding to eReferrals (the amount of effort varies among different departments depending on eReferral volume) and are not additionally incentivized or compensated based on productivity. This model is made feasible by the salary structure at San Francisco General Hospital, which is not based on fee-for-service. Financial consequences of PCE within fee-for-service settings have yet to be determined. As noted above, the recently developed “interprofessional consultation” CPT codes may provide a means for physicians to bill for time spent in PCE, but how these codes will be used and how they will be reimbursed has yet to be seen. The foregoing issues underscore the need for careful monitoring of PCE systems as they continue to develop.

Strengths and Limitation

Our study has strengths and limitations. We surveyed a well-characterized cohort of clinically active internists representative of ACP membership. Approximately 35% of US internists are ACP members, but compared with the overall US internist population, ACP members are 6% more likely to be general internists (rather than subspecialists) and are 7% more likely to work primarily in administration, research, and/or teaching (rather than in clinical practice) (data from ACP Membership Summary, June 2012). These characteristics likely introduce some bias into our results; our results must be interpreted within this context and may not be fully generalizable to all US internists. Furthermore, the survey population was limited to internists, and although this includes a wide variety of both primary and specialty physicians, it excludes noninternist physicians such as family medicine specialists, surgeons, etc. Accordingly, we cannot generalize our findings to all types of physicians. Our response rate was modest at 55%, but we are reassured that analysis of responders and nonresponders did not suggest substantial risk of participation bias. Although physicians in private practice were slightly less likely to respond, this is not uncommon among large, national surveys,⁷ and the absolute difference (7%) was small; this is unlikely to substantially affect our overall results. It is also worth noting that our survey instrument listed possible benefits of PCE several questions before participants were asked to indicate which benefits they agreed with. This may have affected respondents’ reporting of benefits.

CONCLUSIONS

Our study reveals frequent use of PCE among internists in the United States, and strong agreement with potential benefits of PCE. These benefits may be particularly applicable within managed care settings, as PCE has potential to increase not only access to specialty care, but also its timeliness and efficiency. Several significant concerns regarding PCE were illuminated, but responders agreed that proposed remedies would increase likelihood of using PCE. In the setting of healthcare reform, the imperative to study PCE in a scholarly manner, and to enhance its use, will continue to grow in importance.

Acknowledgments

The authors thank Molly Cooke, MD, for her assistance in establishing our authors’ collaboration, and Dawn Wiest, PhD, for her assistance with data preparation and summary statistics. Incentives for survey responders were provided by the American College of Physicians according to the standard protocol for their research survey panel. Two employees of the American College of Physicians collaborated on the study and were involved in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, and approval of the manuscript; and decision to submit the manuscript for publication. Aside from these 2 coauthors, the American College of Physicians as an organization did not play a role in the study.Author Affiliations: Center for Innovation in Access and Quality and Division of Gastroenterology, Department of Medicine, San Francisco General Hospital (JLS, LWD) and School of Medicine (KST), University of California, San Francisco, CA; American College of Physicians (NK, AW), Philadelphia, PA.

Source of Funding: None.

Author Disclosures: The authors report no conflicts of interest.

Authorship Information: Concept and design (JLS, KST, LWD, NK); acquisition of data (JLS, NK, AW); analysis and interpretation of data (JLS, KST, LWD, AW); drafting of the manuscript (JLS, KST); critical revision of the manuscript for important intellectual content (LWD, NK, AW); statistical analysis (JLS, AW); and supervision (JLS, AW).

Address correspondence to: Justin L. Sewell, MD, MPH, San Francisco General Hospital, Division of Gastroenterology, 1001 Potrero Ave, Unit NH 3D3, San Francisco, CA 94110. E-mail justin.sewell@ucsf.edu.REFERENCES

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