Surgical Comanagement by Hospitalists: Continued Improvement Over 5 Years
Neurosurgery services in which the same Internal Medicine hospitalists are dedicated year round to each of these surgical services to proactively prevent and manage medical conditions. In this article, we evaluate if SCM was associated with continued improvement in patient outcomes between 2012 and 2018 in Orthopedic and Neurosurgery services at our institution. We conducted regression analysis on 26,380 discharges to assess yearly change in our outcomes. Since 2012, the odds of patients with ≥1 medical complication decreased by 3.8% per year (P = .01), the estimated length of stay decreased by 0.3 days per year (P < .0001), and the odds of rapid response team calls decreased by 12.2% per year (P = .001). Estimated average direct cost savings were $3,424 per discharge.
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DISCUSSION
Since the implementation of SCM on Orthopedic and Neurosurgery services at our institution, there was a decrease in medical complications, LOS, and rapid response team calls. To our knowledge, this is one of the largest studies evaluating the benefits of SCM over 5.8 years. Similar to our prior studies on this SCM model of care,5,7 other studies have reported a decrease in medical complications,8-10 LOS,11-13 and cost of care14 with SCM.
While the changes in the unadjusted rates of outcomes over the years appeared to be small, while our patient population became older and sicker, there were significant changes in several of our outcomes in the adjusted analysis. We believe that SCM hospitalists have developed a skill set and understanding of these surgical patients over time and can manage more medically complex patients without an increase in medical complications or LOS. We attribute this to our unique SCM model in which the same hospitalists stay year round on the same surgical service. SCM hospitalists have built trusting relationships with the surgical team with greater involvement in decision making, care planning, and patient selection. With minimal turnover in the SCM group and with ongoing learning, SCM hospitalists can anticipate fluid or pain medication requirements after specific surgeries and the surgery-specific medical complications. SCM hospitalists are available on the patient units to provide timely intervention in case of medical deterioration; answer any questions from patients, families, or nursing while the surgical teams may be in the operating room; and coordinate with other medical consultants or outpatient providers as needed.
This study has several limitations. This is a single-center study at an academic institution, limited to two surgical services. We did not have a control group and multiple hospital-wide interventions may have affected these outcomes. This is an observational study in which unobserved variables may bias the results. We used ICD codes to identify medical complications, which relies on the quality of physician documentation. While our response rate of 21.1% for HCAHPS was comparable to the national average of 26.7%, it may not reliably represent our patient population.15 Lastly, we had limited financial data.
CONCLUSION
With the move toward value-based payment and increasing medical complexity of surgical patients, SCM by hospitalists may deliver high-quality care.
