Osteopathic Manipulative Medicine Consultations for Hospitalized Patients

Primary Reasons for Consultation

A single reviewer (V.L.) manually reviewed the text field “primary reason for consult” and subsequently grouped reasons into distinct categories. A second reviewer (C.H.) spot-checked approximately 10% of the records, and both reviewers came to a consensus about any discrepancies. Three broad categories for consultations were created: (1) musculoskeletal; (2) nonspecific, multiple, or other reason; and (3) newborn. For the 95 consultations with no information written in the text field, medical records were manually checked for the consultation reason note and then grouped into categories.

First, musculoskeletal consultations included any consultation for pain or related reasons, including decreased mobility, numbness, weakness, and fatigue of an area. If only 1 region was mentioned in the primary complaint, the consultation was further categorized into a regional group: back, neck, head, extremity, shoulder, hip (including groin), chest/rib, or pelvic and/or abdominal pain. If multiple regions were mentioned, the consultation was categorized as multiple regions. This grouping was further categorized into “back +1 or more regions,” for example, which could include the neck, followed by the next most prevalent single region, eg, “neck +1 or more regions,” which was anything associated with the neck but not including the back.

The second category, “nonspecific, multiple, or other,” included reasons that were either not solely musculoskeletal or did not mention a musculoskeletal region. “General discomfort” included general pain or discomfort without mention of a body region. Other primary categories for consultation not listing a region or a general pain report included postoperative, postpartum, respiratory (including cystic fibrosis), and constipation. “Multiple-reason” consultation orders had multiple reasons listed, such as some of the ones previously described (which may or may not have also included a musculoskeletal region).

The third category was “newborn” (aged <1 year). Newborn feeding difficulty included any consultations related to feeding. “Other newborn” were single-reason consultations not related to feeding, with subcategories of tone, neck and cranium, preterm, and request (if there was nothing else written in the consultation reason field). “Multiple newborn” included any combination of reasons, which often included breastfeeding and something else, other reasons, such as breathing, hip dysplasia, and foot deformity.

Binary Yes/No Categories

While attempting to categorize the data, it was observed that many patients had a primary complaint but also were noted incidentally in the consultation text to be postoperative, postpartum, or pregnant, or have cystic fibrosis. Separate yes/no fields were made to identify the total numbers of these patients in the final counts. For example, a consultation for a patient who had a primary complaint of back pain but happened to be hospitalized for open-heart surgery was counted in the postoperative field, as was a consultation in which the primary reason for consultation was postoperative. Consultations included in the postoperative yes/no field included surgical procedures and procedures mentioned in the free text field. Yes/no fields were also made for postpartum, respiratory, cystic fibrosis, pregnancy, and constipation-related complaints. If a patient had a cesarean delivery, the consultation would be flagged under both the postoperative and postpartum fields. Of note, consultations flagged in the respiratory yes/no field generally had multiple reasons for order and one was specifically respiratory in nature. However, having cystic fibrosis or requiring mechanical ventilation did not count as one of those reasons.

Patient Characteristics

The demographics of patients receiving consultations included slightly more female patients (724 [55%]), predominantly white race (1233 [94.1%]), newborns and infants (425 [32.4%]), and patients older than 65 years (235 [18%]) (Table 1).

A total of 672 patients (51.3%) had commercial insurance, 287 (21.9%) had Medicaid, 329 (25.1%) had Medicare, and 22 (1.7%) had no insurance. Roughly one-fourth of hospital stays lasted less than 48 hours, slightly over half lasted 3 to 14 days, and 260 (20%) lasted longer than 2 weeks. The mean hospital length of stay among all consultations was 11.4 days and among nonnewborn patients, 13.4 days (range, 1-247 days). We did not precisely calculate the mean time from order to consultation.

Approximately half of the consultations (n=618) were on primarily adult floors (Table 1). Among the 481 patients (36.7%) located on pediatric or newborn floors, 369 (28.2%) were healthy newborns, and 36 (2.7%) were in the neonatal intensive care unit or the continuing care nursery (intermediate care unit for newborns). A total of 177 consultations (13.5%) were for pregnant and postpartum women on obstetric floors.

Reasons for Consultations

Table 2 presents the primary reasons for ordering OMM consultations. Of the 1310 consultations included in the study, 620 (47.3%) listed a musculoskeletal complaint as the primary or only reason for consultation; 490 consultations (37.4%) addressed a single region and 130 (9.9%) addressed multiple regions. Overall, 231 consultations (17.6%) were for single-region back pain, followed by single-region neck pain (69 [5.3%]), headache (46 [3.5%]), shoulder pain (43 [3.3%]), and extremity pain (41 [3.1%]). The next most common reason for consultation was for newborn issues (418 [31.9%]), which included feeding difficulty (352 [26.9%]), nonfeeding reason (34 [2.6%]), or multiple reasons (32 [2.4%]). A total of 272 consultations (20.8%) were not limited to musculoskeletal complaints, with the primary reason for consultations being general nonspecific discomfort (7.3%), respiratory complaint (4.0%), and postoperative (3.9%).

When consultations were reviewed for our predetermined binary categories, 209 (16.0%) were found to mention that patients were postoperative, postpartum (124 [9.5%]), had respiratory issues (59 [4.5%]), had cystic fibrosis (57 [4.4%]), were pregnant (57 [4.4%]), or had constipation (21 [1.6%]) (Table 3). Of note, 39 of 209 postoperative consultations (18.7%) were after cesarean delivery and 20 (9.6%) were after coronary artery bypass graft. Twenty-nine of 59 respiratory consultations (49.2%) were for cystic fibrosis.

Repeated Consultations

Sixty-four patients (5.4%) received 2 or more consultations in 1 hospitalization. Consultations are sometimes reordered to alert the OMM team that a patient needs to be seen again more urgently. Most of the consultations were for unique patients (1186 [90.5%]) and for unique hospitalizations (1245 [95.0%]). Forty-eight consultations (4.0%) were for patients who had received OMT in a previous hospitalization during this same 6-month period.

Limitations and Opportunities

Our analysis of the newborn group was limited because age was reported in years, so there may have been more differences in reason for consultation in infants (aged 1 month to 1 year) who were several months old compared with newborns (aged <1 month). Our analysis limited consultations to a 6-month period because of time and resource constraints, but it is possible that there may be a seasonal bias with the types of conditions requiring hospitalization between January and June.

Some other questions addressed in the Kirksville study²⁴ included hospital diagnoses, regions of somatic dysfunction identified, and OMT techniques used, which could be topics for future studies at our institution. We had decided against examining diagnostic codes in the current study because diagnoses can change throughout a hospital stay and may not have necessarily been related to the reason for the OMM consultation. By knowing the reasons for which consultations were requested, it may be easier to specifically study a certain diagnosis, such as the percentage of patients with constipation who received OMT consultations for constipation and the length of time after starting a bowel regimen that the consultation was ordered. Now that we have identified that a relatively small number of OMM consultations were requested for bowel ileus and respiratory complaints, the next step is to examine ways to increase OMT use in these areas, such as through physician knowledge or creating more order sets that include OMM consultation. Perhaps it would be helpful to give a dropdown list of reasons in the OMM order for physicians to see what complaints can commonly be addressed in the inpatient setting. The impact of inclusion of an OMM consultation option in the order sets also warrants further study, for example, if it affects frequency of use. With a large number of initial consultations, it may be interesting to examine the frequency of follow-up treatments for different conditions as well.

Knowing that a large volume of consultations are being ordered in a relatively short period may make future studies more approachable. There is certainly room for studies in multiple areas, including examining the effect of OMT on various conditions.