The comanagement of surgical patients by a team of surgeons and hospitalists yielded improvements in rates of medical complications, 30-day readmissions, consultant involvement, length of hospital stay, and total cost of care per patient, according to a study published in the Annals of Surgery.
“Traditionally, hospitals have utilized a consultation model of care for surgical patients in which the medicine consultants are involved ‘as needed’ [but] this model, though common, may not be the best approach to care for surgical patients,” wrote the investigators, led by Nidhi Rohatgi, MD, MS, of Stanford (Calif.) University. “To address these limitations in the care of surgical patients, we transitioned from the consultation model to surgical comanagement (SCM) model in Orthopedic and Neurosurgery at our institution in August 2012.”
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Dr. Rohatgi and her coinvestigators enrolled 16,930 patients admitted for orthopedic surgery or neurosurgery into the SCM intervention cohort, which was further divided into a preintervention cohort and a postintervention cohort. The former were admitted from January 2009 to July 2012, and the latter from September 2012 to September 2013. A further 3,695 patients were enrolled in a control group, also made up of orthopedic surgery and neurosurgery patients, which was divided into two cohorts of pre- and postcontrol over the same time periods. The two primary outcomes were the proportion of patients that had at least one medical complication – defined as sepsis, pneumonia, urinary tract infections, delirium, acute kidney injury, atrial fibrillation, or ileus – and the proportion of patients with a hospital stay of at least 5 days. Other outcomes included 30-day readmissions, costs, two or more medical consultants, and satisfaction of both patients and providers.
The findings
Overall, the SCM model was associated with a decrease in the proportion of patients with at least one complication (odds ratio, 0.86; 95% confidence interval, 0.74-0.96; P = .008) in the intervention group, compared with the control group. Similarly, there was a reduction in the proportion of patients with a hospital stay of at least 5 days (OR, 0.75; 95% CI, 0.67-0.84; P less than .001). In addition, the SCM model was associated with a reduction in 30-day readmission rates caused by medical complications (OR, 0.67; 95% CI, 0.52-0.81; P less than .001) and a drop in the proportion of patients with two or more medical consultants (OR, 0.55; 95% CI, 0.49-0.63; P less than .001).
The overall rate of provider satisfaction in the SCM cohort was 88.3%, but there was no significant change in patient satisfaction between the pre- and post-intervention cohorts (OR, 1.08; 95% CI, 0.87-1.33; P = .507). Furthermore, Dr. Rohatgi and her coinvestigators estimated that there was at least a $2,642 cost savings per patient, with that number also estimated as being as high as $4,303.
The SCM mode work flow
The SCM model consists of a structured work flow that hospitalists adhere to. On weekdays, an orthopedic and a neurosurgery hospitalist would screen all patients admitted for each respective specialty during the day and would consult with staff after hours to discuss any potential issues they were having with these patients. On weekends, one SCM hospitalist would remain on call to screen patients and consult for both specialities. If a medical intervention was deemed necessary, the SCM on call would formally see the patient to prevent medical complications from occurring.
The SCM would also go on rounds for select patients with the rest of the surgical team, making an effort to keep communication consistent throughout the day. These rounds would be in addition to the daily, multidisciplinary rounds that would include the “surgical team, case managers, social workers, unit nurses, physical and occupational therapists, pharmacist, [and] dietitian.” Additionally, while the surgical team would conduct the discharge summaries, the SCM hospitalists would be the ones response for discharge education, medication reconciliation, and tracking patients every 2 weeks via an electronic tracking system set up by the Stanford Health Care’s Quality and Patient Safety department.
“We postulate the effect of SCM on the quality of patient care has been underestimated due to methodological shortcomings of prior studies,” the authors noted, adding that while “the initial cost of setting up SCM might be perceived as a deterrent, [our] SCM model provided a meaningful return on investment with cost savings.”
No source of funding was provided for this study. Dr. Rohatgi and her coauthors did not report any relevant financial disclosures.