Published in the May 2014 issue of Today’s Hospitalist
WHEN IT COMES TO hospitalist comanagement arrangements, oncology may be one of the last frontiers. Many hospitalists, after all, hesitate to take on a service line where patients are so much sicker than general medical patients and where patients and families need so much more time, support and understanding.
When the hospital medicine department at North Shore University Hospital in Manhasset, N.Y., agreed to take over the medical comanagement of cancer patients from a group of oncologists in 2012, the hospitalists had one big advantage: one of their own wanted to devote most of her practice to oncology comanagement. Two years later, that hospitalist, Rubina Boparai, MD, has a patient census made up almost exclusively of cancer patients. None of her other colleagues in the 26-hospitalist group have had to rotate through the service line.
Dr. Boparai’s focused service has had a major impact on outcomes, according to study results she and her colleagues presented at this year’s Society of Hospital Medicine annual meeting. When they compared outcomes before and after the hospitalists took over cancer patients’ medical management, researchers found that the average length of stay dropped from 8.9 days to 7.3, an impressive 22% reduction.
Patients’ average number of excess days per case “days in excess of what Medicare allows per specific DRG “was cut by more than half, falling from 3.37 to 1.58. Meanwhile, pre- and post-intervention in-hospital mortality rates were exactly the same at 6.6%.
To what does Dr. Boparai credit those reductions in length of stay and excess days?
“My experience as a hospitalist helps a lot,” she says. “Our emphasis is always on decreasing hospital days as much as possible, and our focus is on early discharge when medically feasible.” The oncologists, by comparison, “are traditionally more in tune with outpatient practice and are not as focused on discharge or length of stay.”
A different mindset
Because Dr. Boparai has always had a special interest in cancer patients, the chance to take over oncology comanagement was “a great opportunity.” But she adds that the work does require a certain mindset to be comfortable caring for very sick patients and dealing with the emergencies and complications that arise.
Dr. Boparai explains that she didn’t face a steep learning curve, which is one concern hospitalists have about managing cancer patients. While she’s since attended conferences to develop more of a knowledge base, she was comfortable in the service from the start.
Her boss, David J. Rosenberg, MD, chief of the hospital medicine division, explains why.
“The hospitalists are not giving patients chemotherapy, so no one has to learn a whole textbook on oncology meds,” Dr. Rosenberg says. “These patients may be receiving chemo and have complications from that treatment, but many need pain management or end-of-life care.”
Dr. Rosenberg also points out that the service excludes patients with hematologic malignancies.
“We already have a very strong hematologic malignancy service here that takes patients from the entire region,” Dr. Rosenberg says. “That’s a very different group of patients and skill sets, and that team already has the expertise to do that.”
Still, Dr. Rosenberg acknowledges that oncology comanagement is a specialized service. “You’re dealing with brain metastases, spinal cord compression, febrile neutropenia “conditions you see in these patients over and over again,” he says. “You also need the time and resources to provide support when patients aren’t doing well to help them think through their goals of care.”
Issues with bed management
Dr. Boparai usually works Monday through Friday from 8:30 a.m. to 5 or 5:30 p.m. Her typical daily census on the oncology floor runs between 12 and 16 patients.
Residents or nurse practitioners may also cover some of those patients, she points out. At the end of the day, she signs out her oncology patients to the general hospitalist service that covers them during evenings, nights and weekends.
One unexpected hurdle with the service is that now, bed management has a harder time assigning patients to the oncology floor.
“Those patients used to be admitted through an oncologist, so there was never any problem,” Dr. Rosenberg explains. Now, particularly when patients come in after hours, they’re admitted to the general hospitalist service, not under Dr. Boparai’s name or that of an oncology attending.
“It’s been a challenge getting patients cohorted in the right place,” Dr. Rosenberg notes. “That’s something we didn’t anticipate.”
As for the service line’s success, another big factor is that it’s true comanagement, Dr. Boparai says. While many comanagement lines fall apart because the specialists involved disengage “failing to round on their patients because the hospitalists “are on it” or being difficult to reach by phone “that’s not the case with the oncology service.
“I round every day with the same inpatient oncologist, so the collaboration has been pretty good,” says Dr. Boparai, adding that daily rounds also include nurse practitioners and case managers. According to Dr. Rosenberg, that collaboration sets the service apart from surgical comanagement.
“Surgical subspecialists see their real work as taking place in the OR, so they may limit their involvement after surgery,” he says. “Oncology works much better than other comanagement models.”
He also gives credit to the nurse practitioners on the oncology floor.
“They’re absolutely involved in patient care, not just in patient discharges,” he notes. “They’ve had no special training but have spent so much time on the cancer floor that they’ve become specialized in oncology, and they work with Dr. Boparai very closely.”
Dr. Boparai says she saw one new sign that the ranks of hospitalists doing oncology comanagement is growing at this year’s Society of Hospital Medicine meeting. One of the special interest forums this year was devoted to hospitalists who, like her, comanage cancer patients at major cancer centers like New York’s Memorial Sloan Kettering and M.D. Anderson Cancer Center in Houston.
“We’re planning to collaborate on research projects and work together in the future,” she notes.
And the longer she works on the service almost exclusively, the less the emotional toll. “It’s not easy and it drains you, particularly during the first few months,” Dr. Boparai says. “But you get a certain degree of proficiency, and it becomes easier over time.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.