Published in the January 2005 issue of Today’s Hospitalist
When hospitalists at Community Hospital of the Monterey Peninsula begin co-managing the care of orthopedic surgery patients this year, they will join a rapidly growing trend. As hospitalists around the country look for ways to expand their services, many are getting involved in the care of surgical patients, particularly those undergoing orthopedic procedures.
What makes the new co-management program in Monterey particularly interesting, however, is that it was the 174-bed hospital’s orthopedic surgeons, not the hospitalists, who struck up a discussion about jointly managing their patients. The three-year-old program, which describes itself as “mature,” was looking for new turf to plow.
Physicians say that as orthopedic surgeons struggle to treat a population that is older and sicker, some are becoming uncomfortable managing their patients’ medical issues. “The orthopedists feel less and less comfortable dealing with the myriad problems these people present with,” explains Tony Chavis, MD, vice president of medical affairs at the hospital, “so they stimulated the discussion.”
And while the decision by some surgeons to turn to hospitalists for help can be seen as a vote of confidence in the new specialty, it also presents inpatient physicians with new challenges. Because the model is relatively new, for example, there is not much in the way of a roadmap to follow. While hospitalists in some programs provide evaluation and management from pre-op admission to discharge, others step in only after the surgery is complete.
And while hospitalists may be well-versed in creating the kinds of efficiencies that can reduce length of stay and streamline costs, the goals of co-management programs sometimes take on a slightly different emphasis. Reducing peri- and post-operative risk factors in a patient population that is increasingly older, sicker and comorbid tends to be the emphasis in many co-management programs, and that may require some adjustment on the part of hospitalists.
Here’s a look at how some hospitalist programs are taking on co-management duties for orthopedic surgery patients “and how they’re addressing some of these issues.
Beyond length of stay
Reducing length of stay is definitely a factor driving the emergence of hospitalist-orthopedics co-management programs, but experts say it’s not always the primary goal.
“Most of these patients have medical issues, and the surgeons “especially the highly specialized ones who just do spine or foot surgery “are becoming less comfortable handling those issues,” says Steve Nahm, a vice president of physician services for The Camden Group in El Segundo, Calif., which helps hospitals and physician organizations launch hospitalist programs.
The advancing age of many patients undergoing orthopedic surgery “think joint replacement surgery “is another key factor in the growth of co-management programs.
“Those patients may have been cleared medically before surgery, but if they’re in their seventies or eighties, and if they’re diabetics or if they have coronary artery disease, there are [medicine] issues that need to be addressed from the minute they hit the recovery room,” says Andrew Fishmann, MD, co-founder of Cogent Healthcare Inc. in Irvine, Calif., and a 20-year veteran of orthopedics co-management who practices at Good Samaritan Hospital in Los Angeles.
Dr. Fishmann adds that issues ranging from blood pressure control to accurate tracking of blood sugar and ensuring appropriate DVT prophylaxis “are addressed more comfortably by the medicine people than by orthopedic surgeons.”
That’s why his group has developed a formal DVT screening protocol for all orthopedic patients transferred to Good Samaritan. The initiative has helped hospitalists detect occult DVT “a common problem with transfer patients who weren’t properly screened in the first institution “in more than 14 percent of cases.
“It’s not about reducing length of stay with these elective surgeries anymore, because many hospitals already have good system throughput,” says David Wesorick, MD, a clinical assistant professor and hospitalist at the University of Michigan Medical Center in Ann Arbor, Mich. “It’s about reducing risks for [surgical] patients who are older and sicker. Surgeons just don’t have time to handle many of the things that come up.”
Because hospitalists’ involvement in co-management is growing so rapidly, it’s impossible to quantify the trend. Dr. Fishmann, however, says that three-quarters of Cogent’s programs are providing some sort of orthopedic co-management, and that most either have the means or are “in development to do so.”
Other industry observers echo that assessment of growth. Martin Buser, MPH, a founding partner of Hospitalist Management Resources, LLC, a hospitalist consulting firm with offices in San Diego and Colorado Springs, Colo., estimates that about half of the 100 hospitalist programs his company works with now offer orthopedics co-management services. “The other half are considering it,” he says.
In his view, co-management programs are booming largely because of ER call panel shortages and surgeons’ ever- increasing volumes of procedures. Surgeons are so busy that they don’t want to take ER call anymore, Mr. Buser says, and hospitals are trying to find a solution.
That situation is driving demand for hospitalist co- management at John Muir Medical Center in Walnut Creek, Calif. The 321-bed hospital, which was started by a group of subspecialists two decades ago, is a magnet for highly specialized orthopedic surgeons who perform complex procedures such as spine surgery or acetabulum reconstruction.
“We tend to get more requests for co-management in these situations because the surgeons are focused on doing their thing and may not know about the medical problems that might be involved with some of these patients,” says Russ Everest, MD, a hospitalist with the 10-member group California Hospital Physicians. “What we’re finding is that they feel more comfortable having a generalist involved in the case.”
While the hospitalist group hasn’t formalized its co- management arrangement with the surgeons, it does have a contract with the hospital for ER backup. Most referrals for co-managing surgical care involve nonelective orthopedic and neurosurgery cases that come in through the ER.
The hospitalists’ roles in co-managing surgical patients varies from surgeon to surgeon. In some cases, the hospitalist group assumes an attending role until discharge. In others, much looser arrangements call for a verbal commitment to see patients either daily or as needed.
At the other end of the spectrum is the highly formalized co-management structure at the University of Michigan Medical Center. Hospitalists at the center co-manage total- joint surgical patients, from pre-op evaluation to discharge. Patients are screened at admission by the hospitalist, and they are then followed strictly by the hospitalist after surgery, as long as there are no complications that need to be addressed by the surgeon.
“This gets these patients on our books before they go to the OR,” says Dr. Wesorick, the lead hospitalist on the service. “We bill as consultants, but we actually see the patients every day and manage all of their medicine-type problems.”
Eight of the group’s 10 hospitalists are involved in the University of Michigan program, which was launched last July. The program is unusual because it uses a physician’s assistant (PA) to act as a liaison between the two services. The PA rounds on the patients with the surgeons in the mornings and provides input to the hospitalists before those physicians round on patients later in the day.
“The PA is our touchpoint person,” Dr. Wesorick notes. “Even though the service is designed to get the orthos’ input to the internist, the communication actually works both ways.” He says that the hospitalist pages the PA after making rounds to report any important changes or follow-up details the surgeon ought to know.
The program’s narrowly defined focus also sets it apart from many other co-management arrangements. For now, hospitalists are working with only two orthopedic surgeons and two types of procedures. The hospitalist program chose this structure so it could work out any bugs in the program in a relatively low-volume setting. It sees between five and 10 patients daily. ”
In an academic setting, loosey-goosey doesn’t work,” Dr. Wesorick says. “That’s why we’re working with two particular attendings who do only joint reconstruction.”
Even with such a narrow focus, however, Dr. Wesorick says that communication snafus occasionally occur when, for example, a wound bleed develops. But he adds that for the most part, these situations are worked out with no hard feelings or any interruption in continuity of care.
“Communication is really the key thing,” he explains, “and it will be a big issue for people who are starting these services.” For instance, if the patient develops a fever, the hospitalist makes sure that the surgeon knows that the hospitalist will order a chest X-ray, check it and order the antibiotics if pneumonia is suspected or found.
The University of Michigan group hasn’t started measuring its performance in the co-management program, but Dr. Wesorick says it has been popular with both surgeons and patients. That has also been the consensus at St. Dominic-Jackson Memorial Hospital in Jackson, Miss., where hospitalists co-manage fracture patients and individuals undergoing elective procedures.
“The surgeons are very happy with this overall because it frees them up,” says Frank Criddle III, MD, lead hospitalist for the program, which is part of Cogent. “They also feel that the system is better for the patients.”
Despite the enthusiasm of the hospital’s surgeons, Dr. Criddle acknowledges that rough spots surface from time to time. He says that “it takes a little trial and error” to work through the initial communication issues, adding that hospitalists need to make sure they don’t step on the toes of primary care physicians who admit patients to the hospital.
The four-hospitalist group proposed the idea to admitting orthopedic surgeons as a way to increase its business, and the service has done just that. The Cogent hospitalists now take care of an estimated 80 percent to 90 percent of orthopedics admissions at the 350-bed hospital, and they perform the history and physicals and pre-op workups on fracture patients.
As part of the arrangement, Cogent’s hospitalists agree to try to clear fracture patients for surgery as soon as possible, ideally within 48 hours of their arrival in the ER. The hospital already had a good fracture care pathway in place, Dr. Criddle notes, which made the co-management program easier to start than it might have been in another institution.
Even if a hospital has that kind of structural support in place, Dr. Criddle warns, hospitalists need to obtain buy-in from both hospital officials and surgeons before the program is launched.
“You want to make sure the hospital is on board and that it’s committed to the orthopedics program,” he adds, “that it’s willing to do what it takes to keep the surgeons wanting to operate there. Co-management is a good business model, but it has to be something the hospital and the surgeons want to do.”
To make sure that its surgical co-management program doesn’t run into unforeseen problems, Dr. Chavis from Community Hospital of the Monterey Peninsula says the hospital is making sure that the group “covers as many issues that might come up” and is therefore not “rushing” through the planning process.
Dr. Chavis says that the estimated 20 percent increase in patient volume will require the hospital to add two more hospitalists to its current staff of four. As a result, the hospital wants to ensure the startup issues have been ironed out before that occurs. “Part of the issue is going to be managing that growth,” he explains.
The hospital, which financially supports the hospitalist program, also intends to create very structured agreements between the hospitalists and the surgeons about their respective roles.
“You really need strong agreements between the hospitalist program and the orthopedics folks regarding who manages what and who is captain of the ship,” Dr. Chavis explains. “The other component is assuring that if there is a PCP who’s interested in being involved in the care, we don’t leave that person out.” He notes that under the rules of the program, the surgeon, not the hospitalist, will function as the attending physician.
On the clinical front, ongoing discussions between the hospitalists and surgeons are currently focused on the process that will be used to identify patients at highest risk for post-operative complications and what prophylactic measures will be taken to reduce those risks. “That is our primary strategy, because this isn’t about reducing length of stay, it’s about patient safety,” Dr. Chavis explains.
Surprisingly, one of the issues one might expect to crop up in co-management “billing “hasn’t been a factor. Provided there’s no question about the need for hospitalist consult and the co-management arrangement has been agreed upon verbally or in writing, most groups don’t appear to be experiencing problems.
“I’ve never had a billing company question the charges,” says Dr. Fishmann from the Cogent program at Good Samaritan Hospital in Los Angeles. “Sometimes the HMOs wonder what we’re doing, and I say, ‘Look, I’ve taken what might have been a seven-day stay and reduced it to a four-day stay with no complications. Why would you not want to pay for that?’ ” He adds that the response is, in most cases, a simple “thank you very much.”
Dr. Everest reports a similar response from the billing departments that work with his group. “We just haven’t had a problem with billing coordination,” he says. “People are realizing the value we bring, in being there to address medical problems, preparing patients for discharge or arranging for transfer to skilled nursing.”
Bonnie Darves is a freelance writer specializing in health care. She is based in Lake Oswego, Ore.
A look at co-management outcomes for orthopedic surgery
Just what kind of advantage do hospitalists offer in co-managing orthopedic surgery patients? While there are relatively few data on the topic, a study published in the July 6, 2004, Annals of Internal Medicine found that this type of co-management strategy can improve outcomes.
The study, which was conducted at Mayo Clinic’s Rochester Methodist Hospital, found a far lower incidence of minor complications in post-surgical arthroplasty patients managed by the hospitalist-orthopedics teams, compared to patients managed under the standard model involving orthopedics primary management with a medicine consult.
In addition, 61 percent of patients in the collaborative care group left the hospital with no complications, compared to 49 percent of those treated under the standard arrangement. And the rate of minor complications was far lower “30.2 percent vs. 44.3 percent “in the hospitalist-managed patients, even though length of stay did not differ statistically between the two groups.
The study also found high nursing and orthopedics satisfaction with the arrangement, a bonus that may pay political dividends for groups lobbying for the startup of co-management services.
Although many hospitalist groups are beginning to measure their risk-reduction and outcomes-improvement performance in these collaborative arrangements, few have published results to date.