Published in the June 2015 issue of Today’s Hospitalist
WHILE MANY HOSPITALIST GROUPS have garnered goodwill with comanagement service lines, the evidence backing better outcomes with hospitalist comanagement has been sketchy “until now.
Researchers at New York’s Mount Sinai Hospital studied the outcomes of a new hospitalist comanagement service line for vascular surgery patients. The results, which were posted online in February by the Journal of Vascular Surgery, indicated a nearly fivefold improvement in patient mortality rates (0.37% vs. 1.75%).
While the study found that hospitalist comanagement resulted in a longer length of stay than when surgeons managed patients, that difference was small. Meanwhile, readmission rates between the two patient groups were the same, and reports of moderate pain decreased with comanagement from 14% to 9.6%.
As part of the service, hospitalists also do all preoperative evaluations for vascular surgery patients. But the hospitalists comanage only those patients with an ASA classification of 3 or 4, indicating severe systemic disease. The few vascular surgery patients with an ASA classification of only 1 or 2 are not covered.
While the study looked at only one year of data after the service was launched, the authors plan to publish another study that contains two years of data. Early results from that study indicate that the mortality rate improvement has been sustained, says study coauthor Alan Briones, MD, the director of the comanagement service and of the medicine consult services in Mount Sinai’s division of hospital medicine.
Dr. Briones also points out that the second study indicates that nurses are much more satisfied when vascular-surgery patients are comanaged by hospitalists, rather than having surgeons try to manage patients’ medical problems.
Comanagement is provided by 10 core hospitalists, each of whom works exclusively on the service in two-week rotations. Today’s Hospitalist talked to Dr. Briones, who is one of the hospitalists on rotation.
Other studies have found few improved outcomes from hospitalist comanagement, yet your study found a dramatic improvement in mortality. Why are your results so different?
Because vascular surgery patients are sicker. Many studies looking at hospitalist comanagement have focused on orthopedic patients. Other than hip fracture patients who are high-risk, orthopedic patients tend to be healthier patients having elective surgery.
But with vascular patients, even if they are having a simple procedure, the majority have renal failure, they are on dialysis, they have diabetes, heart failure, stents in their hearts “comorbid conditions that really make expected mortality much higher.
You write in the study that the mortality benefits with comanagement were due to preventing “serious treatable complications.” What are some examples?
Blood pressure control, of course. And we try to prevent renal failure. A lot of vascular patients get angiograms, so they receive a dye that can be very toxic to the kidneys, so we can prevent that before and after any procedure. Patients with diabetes can go into DKA or complications from high blood sugar, or even hypoglycemia when they are NPO before a procedure.
So we do a lot of insulin management. We don’t have any data, but we believe we have decreased our number of consults to the diabetes service due to our ability to control blood sugar.
And when we are treating these cases, we have the opportunity to teach the surgical residents about managing comorbid conditions. I think that helps make them better surgeons.
This service is only for high-risk patients. Is there little value in hospitalists comanaging patients who are less sick?
I think hospitalists bring added value even to simple cases. The majority of postop problems are medical, not surgical. Hospitalists can address acute medical issues much more quickly, which is better for patient satisfaction. Plus, hospitalists tend to do detailed and specific documentation, which improves provider communication.
That said, programs like this can be costly, so you may have to think about your return on investment. It may make the most sense to put hospitalists with high-risk patients, not on a low-risk service. But I do think there is still some value to having hospitalists manage lower-risk patients.
Ten core hospitalists rotate through this service. Are the costs of such a program just beyond what a community hospital could afford for vascular surgery patients?
I think this type of service is perfectly doable in smaller hospitals. You would need daytime coverage, but not necessarily nighttime coverage. You would just need some mechanism for a physician to be accessible at night if something happens.
How do you decide which hospitalists work this service?
I choose doctors based on their skill set, but I also try to pick experienced hospitalists who are more comfortable dealing with surgeons. A lot of the success of this service comes down to communication.
That’s not to say that a hospitalist right out of training couldn’t do this. But I prefer someone who is more senior, especially if we end up recommending a different care plan. Sometimes after a preop evaluation, for instance, we try to dissuade surgeons from doing surgery and say, “Why don’t we try the palliative care route instead?”
Or we may decide to delay surgery until a patient is more stable. A surgeon can override that decision if he or she thinks the patient’s condition is life-threatening, but you have to be able to have that discussion.
Do you meet regularly with your surgical counterpart to make sure the service is running smoothly?
We don’t really have formal meetings, but we check in on each other every day to see how things are going. For this type of service to work, you need a program champion. I am the program champion on the medicine side. The surgeons have their own champion.
You also need a service agreement with very clear goals, responsibilities and workflow. So, for instance, while other hospitals may do this differently, we gave the surgeons the decision to transfuse and they gave pain management to us. You need to clearly spell out who decides which antibiotic the patient should be started on and who decides when to call a consult.
The data included in this study end in October 2013. What has changed with the service since?
We have expanded the comanagement service to include surgical oncology and ENT, targeting only high-risk patients in those areas as well.
As for the vascular surgery service, I plan to eventually incorporate our internal medicine housestaff. The residents we work with now are doing surgical rotations. But my vision is to have a comanagement rotation for second- or third-year internal medicine residents so they can learn how to comanage patients.
There are a lot of things you learn in the surgical service that we don’t see in the medical service, and it really is the wave of the future. I think hospitalists are not just going to treat medical patients. Hospitalists will eventually be in all the surgical wards doing comanagement.
Phyllis Maguire is Executive Editor of Today’s Hospitalist.