A veteran hospitalist takes the heretical position that not all comanagement is good by Phyllis Maguire
Published in the August 2008 issue of Today's Hospitalist
Which of these patients are appropriate for hospitalist comanagement: a 63-year-old with a hemodynamically stable acute upper GI bleed? A 59-year-old with an ST-elevation MI and dyslipidemia? Or a healthy 70-year-old with an elective total knee?
During a provocative talk on comanagement given at the Society of Hospital Medicine annual meeting earlier this year, hospitalists were asked to raise their hands if they were currently managing such patients. While some hands remained in the air for all three examples, presenter Eric Siegal, MD, pointed out that all of these patients are relatively young
“Comanagement might be detrimental in some cases.”
–Eric Siegal MD Cogent Healthcare
and have a “low burden” of medical comorbidity. As a result, he questioned whether comanagement would really be of any value.
According to Dr. Siegal, a regional medical director for Cogent Healthcare, hospitalists generally add little to the care of young patients who have few medical issues and primarily surgical problems. “In fact,” he continued, “I’d argue that comanagement might be detrimental in some of these cases.”
While the idea that hospitalists should provide wide-ranging comanagement is held as dogma by many, Dr. Siegal noted that no one is asking these basic questions: Why are hospitalists comanaging patients in the first place? Who benefits from comanagement, and when?
While Dr. Siegal firmly believes there is a place for comanagement, he wants hospitalists to think more critically about such arrangements. As a group, hospitalists need to learn to identify when comanagement is appropriate—and when it’s likely to go wrong.
Questioning the articles of faith
While just about everyone agrees what comanagement is—shared responsibility and accountability for a patient across different specialties—comanagement practices vary, not only from hospital to hospital, but often among partners in the same group.
“Orthopod A wants you to manage patients’ perioperative anticoagulation,” Dr. Siegal said, “while orthopod B would kneecap you if you tried to manage it.”
So what shouldn’t count as comanagement, but often does? For one, Dr. Siegal said, comanagement should not entail placing yourself in a subordinate position to another specialty.
Nor should it be “serving as a thinly disguised admission service” or a mechanism for hospitalists to replace a disappearing cadre of subspecialists. It should also, Dr. Siegal added, not be an exercise in leaving clinical recommendations that will just be ignored.
Yet hospitals continue to push for indiscriminate comanagement arrangements, Dr. Siegal said, because of the “articles of faith” that have grown up around the practice. One tenet is that, as comanagers, hospitalists catch problems earlier, resulting in better outcomes and more effective use of resources.
Another piece of accepted dogma: Hospitalists leverage scarce physician resources, making it possible for hospitals to make the most of their subspecialty pool.
Still another unquestioned belief is that comanagement “allows your specialists and your surgeons to do what they do best,” Dr. Siegal said. “When we manage the medical stuff, everybody goes home happy.”
So, what’s the problem? According to Dr. Siegal, if you examine those tenets closely, “they’re not categorically true.”
The one rigorous, randomized trial on comanagement, the HOT trial, was published in the July 6, 2004, Annals of Internal Medicine. Conducted at the Mayo Clinic, that trial studied patients undergoing knee or hip replacement who were randomized to either hospitalist or orthopedist perioperative care.
The hospitalist arm had significantly fewer complications, Dr. Siegal pointed out, but only when it came to minor complications. The observed length of stay between the two groups was virtually the same, as were costs. “I think it’s lovely that hospitalists reduced the incidence of UTIs,” said Dr. Siegal, “but that’s hardly a compelling case for the value of comanagement.”
However, a study at Mayo that took place at the same time and looked at hip fracture patients came up with much different results: Length of stay was two days less under hospitalist comanagement.
“Same hospital, same hospitalists, same orthopedists and same procedure, but the patients were different,” Dr. Siegal said. “People who come in for an elective joint replacement are a much healthier cohort than those admitted with broken hips.”
Patients with high rates of comorbidities likewise benefited more from hospitalist comanagement in a study of pediatric spinal fusion patients. Finally, researchers at Montefiore Medical Center found that hospitalist comanagement produced the most benefits for patients who needed “close monitoring or complex discharge planning.”
“The literature, while far from complete,” Dr. Siegal pointed out, “seems to be telling us that hospitalists provide the most benefit to patients who are chronically ill or medically complex.”
The risk of harm
While studies show inconsistent benefits to hospitalist comanagement, Dr. Siegal said there are ways that inappropriate comanagement could harm patients.
For one thing, interjecting hospitalists into a case might delay appropriate care. Admitting a patient with a stable upper GI bleed to a hospitalist, for instance, might delay a GI’s involvement and the endoscopy the patient really needs.
Comanagement arrangements also risk disrupting established lines of communication, he added. “You risk disengaging your subspecialists or surgeons from their patients’ medical progress, or lack thereof,” Dr. Siegal explained. And comanagement can confuse a patient’s family or care team about who they should call in case of trouble.
Finally, he raised what he said is not a trivial point. “You at times saddle patients with an unnecessary medical bill.”
Instead of buying into the belief that comanagement is good for all comers, “my take home is that maybe we ought to be more selective,” he concluded. Hospitalists should prioritize patients who have high perioperative risk or unstable medical comorbidities or who are frail, elderly, chronically ill or cognitively impaired.
Hospitalists are often pressured to implement broader comanagement arrangements to keep valuable subspecialists happy, and to help stretch scarce physician resources, like intensivists and neurologists.
What everyone seems to forget is that “hospital medicine has its own incredible manpower shortage,” Dr. Siegal said. Understaffed hospitalist programs may be stretched too thin when comanaging patients who don’t really need their care. That can accelerate hospitalist burnout and attrition, jeopardize quality of care and ultimately destabilize programs.
And too often, comanagement arrangements push hospitalists outside their scope of practice. “I think it’s wonderful that we’re being asked to learn skills that we weren’t taught in residency,” such as how to manage head bleeds, he said. “But we’re learning on the fly on living human beings with no supervision, feedback or measurement of our competency.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.
A comanagement checklist
TO HELP HOSPITALISTS CHOOSE what types of comanagement they want to provide, Eric Siegal, MD, a regional medical director for Cogent Healthcare, suggested asking the following questions:
What behaviors, good or bad, will we encourage? “The good news is that the orthopedic surgeons will love us,” he said. “The bad news is that we’ll never see them at the bedside again.”
Is this a wise use of our limited resources? If the answer is “no,” Dr. Siegal said, is there another compelling reason to provide comanagement? You might, for example, decide that you need to keep the orthopedists happy, regardless of the value that you bring to their patients’ care. “Sometimes,” he said, “you have to make politically expedient choices.”
Who’s in charge? Dr. Siegal said he’s heard this question posed in this form: Do I make suggestions, or do I make decisions? When comanaging a patient in the ICU, Dr. Siegal said he was told by an intensivist that there are some hospitalists in his group whom the intensivist will allow to make decisions for critically ill patients, while there are others that he will not.
“Maybe that shows good judgment,” Dr. Siegal said, “but from a systems perspective, it’s a nightmare.” Instead, Dr. Siegal said, groups should work to standardize what decisions will be hospitalists’ domain. They also need to work out what happens if you disagree, Dr. Siegal said. “Who makes the final call?”
How do you maintain boundaries? Guard against mission creep, and beware of the danger signs. A major red flag is that “you do things on nights, weekends and holidays that no one will let you do on weekdays,” he said. “Magically, I’m an intensivist after hours.” Another boundary to hold relates to physician skills. “Your group is only as strong as its weakest link,” he pointed out. If one of your hospitalists is not comfortable managing a vent, you need to either pull that physician out of the ICU, or see that no one in the group manages vents. “You absolutely cannot have a two-tier system within your group.”
What are the rules? Dr. Siegal urged hospitalists to sit down with each specialty they’re considering managing patients for and dividing up the potential patient pool. In a previous position, he said, he and the cardiologists decided which diagnoses each of the two services would admit, making those distinctions clear to the ED staff.
And whatever range of comanagement you opt for, be sure to revisit those discussions within a few months. “Perspectives change,” Dr. Siegal said, “sometimes better, sometimes worse.”