Published in the May 2008 issue of Today’s Hospitalist
When the orthopedic surgeon at Riverside Tappahannock Hospital in Tappahannock, Va., wanted hospitalists to start admitting his hip fracture patients, there was some resistance. As hospitalist Randy Ferrance, MD, explains, his group would have preferred to maintain the status quo to keep their census down.
But when the four hospitalists in the group made their case to the orthopedist at the 49-bed hospital, they learned a quick lesson in hospital politics. “There were four of us and only one of him,” Dr. Ferrance says, “but we ended up seeing the value to the hospital in keeping our sole orthopedic surgeon happy and relatively well-rested.”
Now that he’s been admitting hip fracture patients for the better part of a year, Dr. Ferrance says he’s glad the group made that decision. Because the average age of hip fracture patients is 72 and because half of those patients come from nearby nursing homes, he explains, it makes sense for hospitalists to take the leading role.
“With so many of these patients being elderly and having serious comorbid conditions, I think it’s probably better care,” says Dr. Ferrance. “If it was my own mother, I’d rather she was admitted by a physician, not a surgeon.”
As hospital administrators and orthopedists continue to pressure hospitalists to begin either comanagement or primary admitting services for surgeons, hip fracture patients seem an intuitive place to start. Several hospitalist programs, in fact, report success with hip fracture admissions.
But while these patients may seem like ideal candidates for hospitalists because so many hip fracture patients are elderly and have comorbidities, they make some hospitalists nervous.
Some of those concerns stem from the fact that because these patients aren’t coming in for an elective procedure, they can disrupt a hospitalist group’s schedule. But hospitalists are also struggling with the perception that an admitting arrangement would either not work to their financial advantage or would overwhelm the group.
Here’s a look at how other groups are handling requests to admit hip fracture patients.
Southwest Washington Medical Center
Lowell Palmer, MD, the hospitalist program director at Southwest Washington Medical Center in Vancouver, Wash., says that his group has had success admitting hip fracture patients. While the orthopedists continue to admit for hip and knee replacements, the 10-physician hospitalist group, which is affiliated with Cogent Healthcare, generally admits hip fractures who come through the emergency department.
Dr. Palmer says that the idea of hospitalists admitting these patients made so much sense that the group supported the idea. Hospitalists, he says, offer much more expertise in both admission and discharge than their surgical colleagues.
“We like the idea of managing hip fracture patients up-front,” Dr. Palmer explains, “because we can help reduce operative risk by starting perioperative beta-blockers. We also feel it’s critical at the time of discharge that all the plans and appropriate medications are in place for these patients, most of whom end up in skilled nursing facilities.”
Dr. Palmer is quick to credit his group’s admitting success to the collaborative relationship the hospitalists have developed with the orthopedists. More than four years ago, the hospitalist group launched a preoperative service that paved the way to admitting hip fracture patients two years later.
Working together on the preop service, he explains, allowed the hospitalists and orthopedists to standardize issues like anticoagulant options. That process of standardization was carried over into the hospitalists’ hip-fracture admissions.
University of Nebraska Medical Center
Cultivating a relationship, also through preop evaluation and the comanagement of elective surgeries, was likewise instrumental in the decision by another hospitalist group to have hospitalists, not orthopedists, admit hip fracture patients.
In Omaha, University of Nebraska Medical Center hospitalist Jason Shiffermiller, MD, acknowledges that when the topic was first broached, there was some contention over which service should do those admissions.
“The argument was initially between the residents of each service before it was appropriately elevated up to staff physicians,” says Dr. Shiffermiller. “Understandably, the orthopedic residents weren’t comfortable taking care of elderly patients who had even a few medical problems, even though internists view these issues as very simple to manage.”
The hospitalists also felt that hip fractures were a unique orthopedic population. “Not only do patients have more comorbidity,” Dr. Shiffermiller says, “but they’ve almost universally had a fall for which the cause needs to be considered by a hospitalist or medical physician.” Eighteen months later, he says his group is happy that they took on the primary role with hip fractures. Like Dr. Palmer, Dr. Shiffermiller says the key to the group’s success was the fact that it had launched a preop evaluation service and perioperative comanagement service for elective surgeries four years ago.
That’s not to say that success with hip-fracture admissions at University of Nebraska has prompted the hospitalists to begin admitting patients for other specialists. Dr. Shiffermiller says that he and his colleagues remain reluctant, for instance, to admit some general surgery patients.
“If someone has a small bowel obstruction,” he explains, “there’s a lot of consternation over who should admit them.” There’s also a debate about who should be the primary admitting service for stroke patients, with neurology pushing for hospitalists to take on an expanded role.
Valley View Hospital
Payment is one barrier for the hospitalists at Valley View Hospital in Ada, Okla., a 99-bed facility.
Hospitalist Barbara Tuley, MD, who is employed by the hospital, says her group has agreed to provide only selective comanagement of complicated orthopedic patients, including hip fractures. Part of the group’s decision to consult only selectively is the concern that payers like Medicare may increasingly think that hospitalist services “could be ‘milking’ payments over and above the surgical global fee without meeting medical necessity for their involvement.”
She points out that the Centers for Medicare and Medicaid Services considers hospitalist comanagement to be “only ‘housekeeping’ if comanagement provides only an H&P, and daily rounding with progress notes and a discharge summary, but very little management of stable medical problems.”
However, payment problems aren’t the group’s only concern. Hospitalists also worry that any routine comanagement or routine admission of any healthy surgical patients, including hip fractures, will crush their small practice.
“If we did all of that, our census would be unmanageable,” says Dr. Tuley, who is one of only 2.5 full-time equivalent hospitalists working at the hospital. (The hospital uses a physician staffing company for weekend coverage.) “It’s a struggle between the administration and the program to keep our census reasonable and to provide good care.”
And while she notes that hospital administrators two years ago promised all their surgeons that hospitalists would serve as attendings, the hospitalists haven’t been able to deliver on that commitment.
“Fortunately, almost all of our surgeons have since recognized our sometimes overwhelming patient burden,” Dr. Tuley says. “What I’ve told administration is that we need midlevels. Once that happens, we can consider doing more comanagement “as long as it meets medical necessity.”
Gwinnett Medical Center
At Gwinnett Medical Center in Lawrenceville, Ga., the group led by Martin Austin, MD, does not routinely admit hip fracture patients, but it may be moving in that direction soon.
The hospitalists with Gwinnett Inpatient Medical Group currently see these patients on a case-by-case basis. Most patients are admitted by an orthopedist, with the hospitalists doing consults or comanagement.
Dr. Austin says that the hospitalists use the same routine hip fracture orders, as well as the same traction and DVT prophylaxis orders, that the orthopedists use. The hospitalist group is also "hiring additional hospitalists,” he explains, “which should give us the manpower to admit hip fractures.”
He acknowledges that admitting those patients will probably be the same amount of work as their current consulting/comanaging arrangement.
“But there is a perception among some of our docs that it’s worse to admit,” Dr. Austin says. Hospitalists worry, for example, that some patients will not have active medical issues and will be little more than a “dump.”
As for Dr. Austin, he says he would like to see hospitalists admitting all hip fracture patients from ground-level falls, as opposed to patients with hip fractures associated with greater injury, such as those from motor vehicle accidents.
“It produces happier orthopods,” he explains. “Their elective cases are some of the true money-makers for the hospital.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist
Balancing hospitalist admissions and orthopedist urgency
WHEN IT COMES TO TAKING on an admitting role for hip fracture patients, some hospitalists worry that orthopedists might be less quick to operate if the patient isn’t on their service. But according to hospitalists who admit hip fracture patients, that’s not an issue.
Lowell Palmer, MD, the hospitalist program director at Southwest Washington Medical Center in Vancouver, Wash., says that he’s seen no signs of surgical delays under the hospitalists’ admission service.
“We evaluate a patient and call the orthopedists to give them our assessment,” he says. “Generally, that person goes to the operating room within a few hours.”
And at the University of Nebraska Medical Center in Omaha, hospitalist Jason Shiffermiller, MD, says that orthopedists have kept the same sense of urgency about getting patients to surgery as they did when they were admitting hip fracture patients.
“I wouldn’t have predicted that orthopedists would be even more responsive in their role as consultant,” says Dr. Shiffermiller. “I think the influence of having a close working relationship with orthopedists is underestimated.”
Making the business case
THE ROAD TO ROUTINE ADMISSION or even comanagement of hip fractures does not run so smoothly in all programs.
Dennis Kolb, MD, medical director of the TriHealth hospitalist service at Bethesda North Hospital in Cincinnati, Ohio, says that despite pressure to routinely comanage or admit hip fracture patients, the physicians in his group have insisted on limiting their role to consults. To help explain that decision, Dr. Kolb says, the group uses terms that the orthopedists understand: the financial impact.
“I argue that because they get a global fee,” he explains, “we as hospitalists get more money as consultants, not managers.”
Some hospitalists struggle with the perception that admitting hip fractures would not work to their financial advantage.
