A STUDY posted online at the end of last year in the Journal of Hospital Medicine was the first to look at outcomes associated with medical comanagement in one very specific population: hip fracture patients. The authors delved into 2016-17 data from the NSQIP dataset maintained by the American College of Surgeons to gauge the impact of medical comanagement on patient mortality and morbidity.
Their findings: Medical comanagement came up short, with the cohort of patients who’d received medical comanagement actually having worse morbidity and mortality than those who weren’t comanaged. Lead author Bryan Maxwell, MD, MPH, a cardiac anesthesiologist at Legacy Emanuel Medical Center in Portland, Ore., says that he and his colleagues wanted to undertake the study for several reasons.
“It was a combination of wanting to actually see the evidence behind medical comanagement in this population,” Dr. Maxwell says. “We also wanted to move the discussion forward on how best to dedicate resources to patients who typically are old and can be very ill.”
“It may be getting harder to demonstrate additional ongoing benefit from individual comanagement.”
~ Bryan Maxwell, MD, MPH
Legacy Emanuel Medical Center
Was he surprised by the results? “I wasn’t surprised that we didn’t find great benefit,” he admits. “But the fact that outcomes were actually worse in the comanaged group really was a striking demonstration of how sick that population is.”
This group of patients, he adds, “is not going to do perfectly, no matter what we do.” (The average age of those being comanaged was 83 vs. 81 in the non-comanaged cohort.) “The question then becomes how to improve quality of life as much as possible.”
The results also suggest that dedicated, individual medical comanagement—at least for some hip fracture patients—may not be the best use of increasingly strained hospital resources. Dr. Maxwell spoke with Today’s Hospitalist.
Do different specialties have different points of view when it comes to comanagement?
You do see different perspectives when you speak to surgeons vs. hospitalists. Even in the best of scenarios where everyone’s feeling very cooperative, you find different incentives and viewpoints.
If, for instance, you’re a busy surgeon and someone’s offering to do a lot of your patient management work for you, that sounds great. But if you’re a hospitalist being flooded with orthopedic surgery patients, that may not feel as right. From the sort of 10,000-foot view, I think the question is: Where are resources being devoted, and is that helping improve outcomes in a way that’s worth it?
Here’s another component: Many of the original studies that looked at comanagement were talking about moving from a paradigm that had no comanagement to introducing it.
Now—and this is one thing we speculate about toward the end of our study to possibly explain the results—perhaps there has been enough education and development of algorithms and clinical pathways that include some benefits and insights originally gleaned from comanagement. Perhaps those have taken root in the care of these patients so we don’t necessarily need someone writing individual orders or progress notes every day.
What are some of those developments?
So the comanagement piece does not get at a number of things we have done in anesthesia to improve pathways for these patients.
Over the past 10 or so years, the anesthesia community has moved to think about the entire perioperative experience as part of our domain, not just when patients are under general anesthesia. That’s true not only in the ICU but in stepdown and other postop units—and, to an increasing degree, in preop care as well. One new pathway in some emergency rooms is that hip fracture patients get an anesthesia consult and a nerve block to help with pain, as opposed to just being given opiates.
And everyone now thinks more sensitively about medication management in this population to avoid agents like benzodiazepines and some anti-nausea medications that are not advantageous in older folks. There’s also more careful fluid management, nutrition and postop mobility, which are all categorized under a set of programs abbreviated as ERAS for enhanced (or early) recovery after surgery. Such programs standardize and optimize these perioperative variables as much as possible to reduce delirium and length of stay and to discharge patients home.
Where does your research leave medical comanagement for hip fracture patients?
I don’t think comanagement is going away, by any means. But I think the conversation will likely evolve to focus on where we think comanagement can really be used to benefit.
Perhaps we need a triaging process to identify patients at particularly high risk for having problems, and they get comanagement. Meanwhile, a cohort that’s not quite as complex could be managed more independently with protocols that hospitalists and geriatric specialists help develop. That makes sense, given the arc of practice patterns shifting from a default of every surgeon doing it all on his or her own to comanagement becoming much more common. Now, it may be getting harder to demonstrate additional ongoing benefit from individual comanagement.
Another component we couldn’t tease out looking at this dataset is how individual comanagement may play out in terms of payer status and different types of reimbursement going forward. Bundled payments and how the CMS decides to reimburse on quality may also factor into this question of resource allocation.
Phyllis Maguire is Executive Editor of Today’s Hospitalist.Published in the February 2020 issue of Today’s Hospitalist