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Xi S, Wang B, Su Y, Lu Y, Gao L. Predicting perioperative myocardial injury/infarction after noncardiac surgery in patients under surgical and medical co-management: a prospective cohort study. BMC Geriatr 2024; 24:540. [PMID: 38907213 PMCID: PMC11193176 DOI: 10.1186/s12877-024-05130-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 06/06/2024] [Indexed: 06/23/2024] Open
Abstract
BACKGROUND Perioperative myocardial injury/infarction (PMI) following noncardiac surgery is a frequent cardiac complication. This study aims to evaluate PMI risk and explore preoperative assessment tools of PMI in patients at increased cardiovascular (CV) risk who underwent noncardiac surgery under the surgical and medical co-management (SMC) model. METHODS A prospective cohort study that included consecutive patients at increased CV risk who underwent intermediate- or high-risk noncardiac surgery at the Second Medical Center, Chinese PLA General Hospital, between January 2017 and December 2022. All patients were treated with perioperative management by the SMC team. The SMC model was initiated when surgical intervention was indicated and throughout the entire perioperative period. The incidence, risk factors, and impact of PMI on 30-day mortality were analyzed. The ability of the Revised Cardiac Risk Index (RCRI), frailty, and their combination to predict PMI was evaluated. RESULTS 613 eligible patients (mean [standard deviation, SD] age 73.3[10.9] years, 94.6% male) were recruited consecutively. Under SMC, PMI occurred in 24/613 patients (3.9%). Patients with PMI had a higher rate of 30-day mortality than patients without PMI (29.2% vs. 0.7%, p = 0.00). The FRAIL Scale for frailty was independently associated with an increased risk for PMI (odds ratio = 5.91; 95% confidence interval [CI], 2.34-14.93; p = 0.00). The RCRI demonstrated adequate discriminatory capacity for predicting PMI (area under the curve [AUC], 0.78; 95% CI, 0.67-0.88). Combining frailty with the RCRI further increased the accuracy of predicting PMI (AUC, 0.87; 95% CI, 0.81-0.93). CONCLUSIONS The incidence of PMI was relatively low in high CV risk patients undergoing intermediate- or high-risk noncardiac surgery under SMC. The RCRI adequately predicted PMI. Combining frailty with the RCRI further increased the accuracy of PMI predictions, achieving excellent discriminatory capacity. These findings may aid personalized evaluation and management of high-risk patients who undergo intermediate- or high-risk noncardiac surgery.
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Affiliation(s)
- Shaozhi Xi
- Department of Comprehensive Surgery, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, No.28 Fu Xing Road, Beijing, 100853, China
| | - Bin Wang
- Department of Comprehensive Surgery, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, No.28 Fu Xing Road, Beijing, 100853, China
| | - Yanhui Su
- Department of Comprehensive Surgery, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, No.28 Fu Xing Road, Beijing, 100853, China
| | - Yan Lu
- Department of Comprehensive Surgery, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, No.28 Fu Xing Road, Beijing, 100853, China.
| | - Linggen Gao
- Department of Comprehensive Surgery, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, No.28 Fu Xing Road, Beijing, 100853, China.
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Foley MP, Westby D, Walsh SR. Systematic Review and Meta-analysis of the Impact of Surgeon-Physician Co-management Models on Short Term Outcomes for Vascular Surgery Inpatients. Eur J Vasc Endovasc Surg 2024:S1078-5884(24)00383-6. [PMID: 38735522 DOI: 10.1016/j.ejvs.2024.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 04/19/2024] [Accepted: 05/02/2024] [Indexed: 05/14/2024]
Abstract
OBJECTIVE As the population ages, vascular surgeons are treating progressively older, multimorbid patients at risk of peri-operative complications. An embedded physician has been shown to improve outcomes in general and orthopaedic surgery. This systematic review and meta-analysis aimed to investigate the impact of surgeon-physician co-management models on morbidity and mortality rates in vascular inpatients. DATA SOURCES PubMed, Scopus, Embase, conference abstract listings, and clinical trial registries. REVIEW METHODS Studies comparing adult vascular surgery inpatients under co-management with standard of care were eligible. The relative risks (RRs) of death, medical complications, and 30 day re-admission between co-management and standard care were calculated. The effect of co-management on the mean length of stay was calculated using weighted means. Risk of bias was assessed using the Methodological Index for Non-Randomised Studies, and certainty assessment with the GRADE analysis tools. RESULTS No randomised controlled trials were identified. Eight single institution studies between 2011 and 2020 with 7 410 patients were included. All studies were observational using before-after methodology. Studies were of high to moderate risk of bias, and outcomes were of very low GRADE certainty of evidence. Co-management was associated with a statistically significant lower relative risk of death (RR 0.64, 95% confidence interval [CI] 0.44 - 0.92; p = .02), cardiac complications (RR 0.47, 95% CI 0.25 - 0.87; p = .02), and infective complications (RR 0.49, 95% CI 0.35 - 0.67; p < .001) in vascular inpatients. No statistically significant differences in length of stay (standard mean difference -0.6 days, 95% CI -1.44 - 0.24 days; p = .16) and 30 day re-admission (RR 0.96, 95% CI 0.84 - 1.08; p = .49) were noted. CONCLUSION Early results of physician and surgeon co-management for vascular surgery inpatients showed promising results from very low certainty data. Further well designed, prospective studies are needed to determine how to maximise the impact of physicians within a vascular service to improve patient outcomes while using hospital resources effectively.
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Affiliation(s)
- Megan Power Foley
- University College Hospital Galway, Galway, Ireland; Royal College of Surgeons in Ireland, Dublin, Ireland.
| | | | - Stewart R Walsh
- University College Hospital Galway, Galway, Ireland; Royal College of Surgeons in Ireland, Dublin, Ireland; Lambe Institute of Translational Research, University of Galway, Galway, Ireland; National Surgical Research Support Centre, Royal College of Surgeons in Ireland, Dublin, Ireland
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3
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El Naamani K, Tjoumakaris SI, Gooch MR, Rosenwasser RH, Jabbour PM. The 30-Day Readmission Rate in Neurosurgery: A New Metric for Reimbursement. World Neurosurg 2024; 185:440-441. [PMID: 38494354 DOI: 10.1016/j.wneu.2024.02.116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Affiliation(s)
- Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Stavropoula I Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Michael R Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Pascal M Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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Xi S, Chen Z, Lu Q, Liu C, Xu L, Lu C, Cheng R. Comparison of laparoscopic and open inguinal-hernia repair in elderly patients: the experience of two comprehensive medical centers over 10 years. Hernia 2024:10.1007/s10029-024-03004-0. [PMID: 38573484 DOI: 10.1007/s10029-024-03004-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 02/23/2024] [Indexed: 04/05/2024]
Abstract
PURPOSE The safety of laparoscopic inguinal-hernia repair must be carefully evaluated in elderly patients. Very little is known regarding the safety of the laparoscopic approach in elderly patients under surgical and medical co-management (SMC). Therefore, this study evaluated the safety of the laparoscopic approach in elderly patients, especially patients with multiple comorbidities under SMC. METHODS From January 2012 to December 2021, patients aged ≥ 65 years who underwent open or laparoscopic inguinal-hernia repair during hospitalization were consecutively enrolled. Postoperative outcomes included major and minor operation-related complications, and other adverse events. To reduce potential selection bias, propensity score matching was performed between open and laparoscopic groups based on patients' demographics and comorbidities. RESULTS A total of 447 elderly patients who underwent inguinal-hernia repair were enrolled, with 408 (91.3%) underwent open and 39 (8.7%) laparoscopic surgery. All postoperative outcomes were comparable between open and laparoscopic groups after 1:1 propensity score matching (all p > 0.05). Moreover, compared to the traditional care group (n = 360), a higher proportion of the SMC group (n = 87) was treated via the laparoscopic approach (18.4% vs. 6.4%, p = 0.00). In the laparoscopic approach subgroup (n = 39), patients in the SMC group (n = 16) were older with multiple comorbidities but were at higher risks of only minor operation-related complications, compared to those in the traditional care group. CONCLUSIONS Laparoscopic inguinal-hernia repair surgery is safe for elderly patients, especially those with multiple comorbidities under SMC.
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Affiliation(s)
- S Xi
- Department of Comprehensive Surgery, The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, No. 28 Fu Xing Road, Beijing, 100853, China
| | - Z Chen
- Department of General Surgery, First Medical Center of Chinese PLA General Hospital, No. 28 Fu Xing Road, Beijing, 100853, China
| | - Q Lu
- Department of Comprehensive Surgery, The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, No. 28 Fu Xing Road, Beijing, 100853, China
| | - C Liu
- Department of Comprehensive Surgery, The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, No. 28 Fu Xing Road, Beijing, 100853, China
| | - L Xu
- Department of Comprehensive Surgery, The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, No. 28 Fu Xing Road, Beijing, 100853, China
| | - C Lu
- Department of General Surgery, First Medical Center of Chinese PLA General Hospital, No. 28 Fu Xing Road, Beijing, 100853, China.
| | - R Cheng
- Department of Comprehensive Surgery, The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, No. 28 Fu Xing Road, Beijing, 100853, China.
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Greenberg B, Jiang S, Nadler A. Postoperative protocols for older adults undergoing emergency surgery: a scoping review. Can J Surg 2024; 67:E149-E157. [PMID: 38575179 PMCID: PMC11001382 DOI: 10.1503/cjs.011323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2023] [Indexed: 04/06/2024] Open
Abstract
BACKGROUND As the population of older adults expands, it is becoming increasingly crucial to develop perioperative protocols to meet their physiologic, functional, and cognitive demands after emergency surgery. We sought to identify protocols that improve the disposition, length of stay, and overall health outcomes of older adults undergoing emergency intracavitary, noncardiac surgery. METHODS Embase, Cochrane, and MEDLINE databases were searched, and results were deduplicated and uploaded to Covidence. We reviewed studies for postoperative interventions that reduced delirium, maintained functional status, and reduced length of stay in older patients undergoing emergency surgery. We included studies involving patients aged 65 years and older undergoing emergency intracavitary, noncardiac surgeries. Abstracts and full texts were reviewed by 2 reviewers. Data were extracted on the postoperative interventions used and the resulting patient outcomes. RESULTS We included 6 studies, which involved patients undergoing emergency general, urology, and vascular surgery. Interventions included a multidisciplinary approach, early involvement of a geriatrician or hospitalist, targeted geriatric-led ward rounds, unique postoperative order sets, and volunteer-driven activities. Standard care included early removal of lines, early mobility, optimal hydration, and medication review. These interventions were associated with decreased length of stay, decreased postoperative complications, and increased likelihood of disposition to home and previous functional status. Frailty was correlated with worse outcomes. CONCLUSION Through multidisciplinary interventions, a successful postoperative protocol for older patients undergoing emergency surgery is helpful for improving patient outcomes. The implications of these findings will help guide our own quality-improvement initiative to improve these outcomes in this patient population at our institution.
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Affiliation(s)
- Brianna Greenberg
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Greenberg, Jiang); and the Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Nadler)
| | - Stephanie Jiang
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Greenberg, Jiang); and the Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Nadler)
| | - Ashlie Nadler
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Greenberg, Jiang); and the Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Nadler)
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6
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Osborne AF, Aung AK, Johnson D, Gibb CL, Mudge AM. General physicians and perioperative medicine. What is on the horizon? Intern Med J 2024; 54:12-15. [PMID: 38267383 DOI: 10.1111/imj.16250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 09/20/2023] [Indexed: 01/26/2024]
Affiliation(s)
- Amy F Osborne
- Department of General Internal Medicine, St. Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Ar Kar Aung
- Department of General Medicine, Alfred Hospital, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Douglas Johnson
- Departments of General Medicine and Infectious Diseases, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Medicine, Royal Melbourne Hospital, Melbourne University, Melbourne, Victoria, Australia
- Medical School, University of Queensland, Brisbane, Queensland, Australia
| | - Catherine L Gibb
- Perioperative Medicine Service, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Alison M Mudge
- Medical School, University of Queensland, Brisbane, Queensland, Australia
- Department of Internal Medicine and Aged Care, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
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7
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Lu W, Liu C, He J, Wang R, Gao D, Cheng R. Surgical and medical co-management optimizes surgical outcomes in older patients with chronic diseases undergoing robot-assisted laparoscopic radical prostatectomy. Aging Male 2023; 26:2159368. [PMID: 36974926 DOI: 10.1080/13685538.2022.2159368] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
INTRODUCTION While robotic-assisted laparoscopic radical prostatectomy (RRP) is a standard mode for localized prostate cancer (PC), the risk of complications in older patients with chronic diseases and complex medical conditions can be a deterrent to surgery. Surgical and medical co-management (SMC) is a new strategy to improve patients' healthcare outcomes in surgical settings. METHODS We reviewed the clinical data of older patients with chronic diseases who were cared for with SMC undergoing RRP in our hospital in the past 3 years and compared them with the clinical data from the general urology ward. Preoperative conditions and related indicators of recovery, and incidence of postoperative complications with the Clavien Grade System were compared between these two groups. RESULTS The indicators of recovery were significantly better, and the incidence rates of complications were significantly reduced in the SMC group at grades I-IV (p < 0.05), as compared to the general urology ward group. CONCLUSIONS The provision of care by SMC for older patients focused on early identification, comorbidity management, preoperative optimization, and collaborative management would significantly improve surgical outcomes. The SMC strategy is worthy of further clinical promotion in RRP treatment in older men with chronic diseases and complex medical conditions.
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Affiliation(s)
- Wenning Lu
- Department of Comprehensive Surgery, the Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Chaoyang Liu
- Department of Comprehensive Surgery, the Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Jing He
- Department of Comprehensive Surgery, the Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Rong Wang
- Department of Comprehensive Surgery, the Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Dewei Gao
- Department of Comprehensive Surgery, the Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Rui Cheng
- Department of Comprehensive Surgery, the Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
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Kim ES, Ohn JH, Lim Y, Lee J, Kim HW, Kim SW, Ryu J, Park HS, Cho JH, Oh JJ, Byun SS, Jang HC, Kim NH. Effect of Active Surgical Co-Management by Medical Hospitalists in Urology Inpatient Care: A Retrospective Cohort Study. Yonsei Med J 2023; 64:558-565. [PMID: 37634632 PMCID: PMC10462814 DOI: 10.3349/ymj.2023.0143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 06/15/2023] [Accepted: 06/30/2023] [Indexed: 08/29/2023] Open
Abstract
PURPOSE This study aimed to evaluate the use of active surgical co-management (SCM) by medical hospitalists for urology inpatient care. MATERIALS AND METHODS Since March 2019, a hospitalist-SCM program was implemented at a tertiary-care medical center, and a retrospective cohort study was conducted among co-managed urology inpatients. We assessed the clinical outcomes of urology inpatients who received SCM and compared passive SCM (co-management of patients by hospitalists only on request; March 2019 to June 2020) with active SCM (co-management of patients based on active screening by hospitalists; July 2020 to October 2021). We also evaluated the perceptions of patients who received SCM toward inpatient care quality, safety, and subjective satisfaction with inpatient care at discharge or when transferred to other wards. RESULTS We assessed 525 patients. Compared with the passive SCM group (n=205), patients in the active SCM group (n=320) required co-management for a significantly shorter duration (p=0.012) and tended to have a shorter length of stay at the urology ward (p=0.062) and less frequent unplanned readmissions within 30 days of discharge (p=0.095) while triggering significantly fewer events of rapid response team activation (p=0.002). No differences were found in the proportion of patients transferred to the intensive care unit, in-hospital mortality rates, or inpatient care questionnaire scores. CONCLUSION Active surveillance and co-management of urology inpatients by medical hospitalists can improve the quality and efficacy of inpatient care without compromising subjective inpatient satisfaction.
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Affiliation(s)
- Eun Sun Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
- Hospital Medicine Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jung Hun Ohn
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
- Hospital Medicine Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Yejee Lim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
- Hospital Medicine Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jongchan Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
- Hospital Medicine Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hye Won Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
- Hospital Medicine Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sun-Wook Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
- Hospital Medicine Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jiwon Ryu
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
- Hospital Medicine Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hee-Sun Park
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
- Hospital Medicine Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jae Ho Cho
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
- Hospital Medicine Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jong Jin Oh
- Department of Urology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Seok-Soo Byun
- Department of Urology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Hak Chul Jang
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
- Hospital Medicine Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Nak-Hyun Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
- Hospital Medicine Center, Seoul National University Bundang Hospital, Seongnam, Korea.
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Hospitalist Co-Management of Urethroplasty Patients in an Academic Center: Implementation of a Standardized Postoperative Care Model. URO 2023. [DOI: 10.3390/uro3010010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Abstract
Objectives: to evaluate whether hospitalist co-management would lead to improved outcomes and value in patients undergoing urethroplasty (UPL) with a single surgeon for urethral stricture disease (USD). Material: A co-management model with hospitalists was introduced in August 2019 for all patients undergoing UPL for USD with a single surgeon in a United States teaching center. The hospitalist worked closely with the urologic surgeon and the support staff. The hospitalist managed post-operative concerns, such as pain and comorbidities, as well as conducted rounds with the urological team for disposition planning and addressing interdisciplinary needs. Retrospective analysis compared a 42-month period before initiation of co-management (Jan 2016–July 2019) with a 32-month period after initiation (Aug 2019–March 2022). Outcomes assessed were recurrence of stricture, complications, length of stay, readmission, and emergency room visits. Results: A total of 135 patients (71 surgeon-managed, 64 co-managed) underwent urethroplasty from January 2016 to March 2022. Hospitalist co-management did not affect complications, length of stay, readmission, and emergency room visits. Accounting for confounding variables using multivariable analysis, no factors were independently associated with recurrence. There were no demographic, comorbidity, or American Society of Anesthesiologists (ASA) score differences between the two groups. Conclusions: This study suggests that hospitalist care for patients undergoing urethroplasty may be non-inferior to surgeon care, based on similar outcomes between the two groups. There were no significant differences in the total length of stay or blood pressure readings, and the complication rates and hospital readmission rates were also similar.
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Evans J, Chan J, Saraqini DH, Mallick R. Is there a role for referral of high-risk patients seen in preoperative medical consultation for postoperative inpatient follow-up? J Perioper Pract 2023; 33:76-81. [PMID: 34396824 DOI: 10.1177/17504589211031076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The potential benefit of referring select high-risk surgical patients who are seen during a preoperative medical consultation for postoperative inpatient medical follow-up is uncertain. Over a seven-year period, our internal medicine perioperative clinic referred 5% of 4642 preoperative consults for postoperative follow-up. A retrospective chart review found that although reasons for referral were heterogeneous, those assessed by the medical consult team postoperatively were more comorbid, had more adverse medical complications and had longer hospital admissions compared to those not referred. Physicians were best able to predict adverse cardiac and diabetes-related complications. Half of the patients who were referred for postoperative assessment were lost to follow-up, and there was a trend towards increased hospital readmissions in this group. Further research is required to identify the subset of patients who might benefit from postoperative inpatient medical assessment.
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Affiliation(s)
- Jessica Evans
- Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - James Chan
- Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | | | - Ranjeeta Mallick
- The Ottawa Methods Center, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada
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11
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Salenger R, Martin W. Physician Leadership in the Employed Universe. Hosp Top 2022; 100:151-158. [PMID: 34635036 DOI: 10.1080/00185868.2021.1938768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Physicians are increasingly becoming employed by hospitals and health systems. While associated with less professional autonomy, such employment offers physicians the opportunity to become leaders within a vertically integrated healthcare environment. Multidisciplinary care teams, led by physician champions, can impact care for a large swath of patients and establish clinical excellence. Successful teams can improve outcomes, increase professional satisfaction, and potentially set physicians on a path to becoming leaders within their health system.
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Affiliation(s)
- Rawn Salenger
- Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Division of Cardiac Surgery, University of Maryland Saint Joseph Medical Center, Towson, Maryland, USA
| | - William Martin
- Department of Management, Depaul University, Chicago, Illinois, USA
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12
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Sambri A, Fiore M, Tedeschi S, De Paolis M. The Need for Multidisciplinarity in Modern Medicine: An Insight into Orthopaedic Infections. Microorganisms 2022; 10:microorganisms10040756. [PMID: 35456807 PMCID: PMC9028939 DOI: 10.3390/microorganisms10040756] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 03/30/2022] [Indexed: 02/04/2023] Open
Affiliation(s)
- Andrea Sambri
- Orthopaedics and Traumatology Department, IRCCS Azienda Ospedaliero Universitaria di Bologna, Via Massarenti 9, 40138 Bologna, Italy; (M.F.); (M.D.P.)
- Correspondence:
| | - Michele Fiore
- Orthopaedics and Traumatology Department, IRCCS Azienda Ospedaliero Universitaria di Bologna, Via Massarenti 9, 40138 Bologna, Italy; (M.F.); (M.D.P.)
| | - Sara Tedeschi
- Infectious Disease Department, IRCCS Azienda Ospedaliero Universitaria di Bologna, Via Massarenti 9, 40138 Bologna, Italy;
| | - Massimiliano De Paolis
- Orthopaedics and Traumatology Department, IRCCS Azienda Ospedaliero Universitaria di Bologna, Via Massarenti 9, 40138 Bologna, Italy; (M.F.); (M.D.P.)
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13
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Shashar S, Polischuk V, Friesem T. Internal medicine physician embedded in an orthopedic service in a level 1 hospital: clinical impact. Intern Emerg Med 2022; 17:339-348. [PMID: 33904116 DOI: 10.1007/s11739-021-02745-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Accepted: 04/12/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The aim of our study was to evaluate the impact of an internist physician specialized in diabetes, appointed as an in-house physician in the orthopedic wards, on improving clinical outcomes and in particular 30-day mortality. METHODS We analyzed a cohort of patients hospitalized more than 24 h in the orthopedic service. The analyses included a comparative analysis between the pre- and post-intervention time periods and an interrupted time series (ITS) analysis, which were conducted in stratification to three populations: whole population, patients with at least one chronic disease and/or older than 75 years of age and patients diagnosed with diabetes. The primary outcome was 30-day mortality following the hospitalization. RESULTS A total of 11,546 patients were included in the study, of which 19% (2212) were hospitalized in the post intervention period. Although in the comparative analysis there was no significant change in 30-day mortality, in the ITS there was a decrease in the mortality trend during the post intervention period in the entire and chronic disease/elderly populations, compared to no change during the pre-intervention period: a post-intervention slope of - 0.14(p value < 0.001) and - 0.11(p value = 0.03), respectively. Additionally, we found decrease in length of stay, increase in transfers to the internal medicine department with a negative trend, increase in HbA1c testing during the hospitalization and changes in diabetes drugs administration. CONCLUSION The presence of an internist in the orthopedic wards is associated with health care improvement; decrease in the 30-day mortality trend, decrease in length of stay, increase in HbA1c testing during the hospitalization and an increase in diabetes drugs administration.
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Affiliation(s)
- Sagi Shashar
- Clinical Research Center, Soroka University Medical Center, Ben-Gurion University of the Negev, P.O.Box 151, 84101, Be'er Sheva, Israel.
| | - Vera Polischuk
- Orthopedic Surgery Service, Soroka University Medical Center, Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - Tai Friesem
- Chairmen of Orthopedic Surgery, Soroka University Medical Center, Ben-Gurion University of the Negev, Be'er Sheva, Israel
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Hospitalist Co-management of a Vascular Surgery Service Improves Quality Outcomes and Reduces Cost. Ann Vasc Surg 2021; 80:12-17. [PMID: 34780942 DOI: 10.1016/j.avsg.2021.09.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Revised: 09/16/2021] [Accepted: 09/18/2021] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Hospitalists can be instrumental in management of inpatients with multiple comorbidities requiring complex medical care such as vascular surgery patients, as well as an expertise in health care delivery. We instituted a unique hospitalist co-management program and assessed length of stay, 30-day readmission rates and mortality, and performed an overall cost-analysis. METHODS Hospitalist co-management of vascular surgery inpatients was implemented beginning April 2019, and data was studied until March 2020. We compared this data to an eight-month period prior to implementing co-management (7/2018 - 3/2019). Patient-related outcomes that were assessed include length of stay, re-admission index, mortality index, case-mix index. Cost-analysis was performed to look at indirect and direct cost of care. RESULTS A total of 1,062 patients were included in the study 520 pre co-management and 542 patients were post-comanagement. Baseline case-mix index was 2.47, and post-comanagement was 2.46 (p>0.05). In terms of average length of stay (aLOS), the baseline aLOS was 5.16 days per patient, while after co-management it was significantly decreased by 1.25 days to 3.91 days (p<0.05). This improvement in length of stay opened an average of 2.4 telemetry beds per day. Similarly, excess days per patient which reflects the expected length of stay based on comorbidities, improved from -0.59 to -1.65, an improvement of -1.46. CONCLUSIONS Hospitalist co-management improves outcomes for vascular surgery inpatients, decreases length of stay, re-admission and mortality while providing a significant cost-savings. The overall average variable direct cost decreased by $1,732 per patient. CONCLUSION Hospitalist co-management improves outcomes for vascular surgery inpatients, decreases length of stay, re-admission and mortality while providing a significant cost-savings.
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Thillainadesan J, Aitken SJ, Monaro SR, Cullen JS, Kerdic R, Hilmer SN, Naganathan V. Geriatric Comanagement of Older Vascular Surgery Inpatients Reduces Hospital-Acquired Geriatric Syndromes. J Am Med Dir Assoc 2021; 23:589-595.e6. [PMID: 34756839 DOI: 10.1016/j.jamda.2021.09.037] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 09/27/2021] [Accepted: 09/28/2021] [Indexed: 02/08/2023]
Abstract
OBJECTIVE This study evaluates the impact of a novel model of care called Geriatric Comanagement of Older Vascular surgery inpatients on clinical outcomes. DESIGN, SETTING, AND PARTICIPANTS A pre-post study of geriatric comanagement, comparing prospectively recruited preintervention (February-October 2019) and prospectively recruited postintervention (January-December 2020) cohorts. Consecutively admitted vascular surgery patients age ≥65 years at a tertiary academic hospital in Concord and with an expected length of stay (LOS) greater than 2 days were recruited. INTERVENTION A comanagement model where a geriatrician was embedded within the vascular surgery team and delivered proactive comprehensive geriatric assessment based interventions. METHODS Primary outcomes of incidence of hospital-acquired geriatric syndromes, delirium, and LOS were compared between groups using univariable and multivariable logistic regression analyses. Prespecified subgroup analysis was performed by frailty status. RESULTS There were 150 patients in the preintervention group and 152 patients in the postintervention group. The postintervention group were more frail [66 (43.4%) vs 45 (30.0%)], urgently admitted [72 (47.4%) vs 56 (37.3%)], and nonoperatively managed [52 (34.2%) vs 33 (22.0%)]. These differences were attributed to the coronavirus disease 2019 pandemic during the postintervention phase. The postintervention group had fewer hospital-acquired geriatric syndromes [74 (48.7%) vs 97 (64.7%); P = .005] and reduced incident delirium [5 (3.3%) vs 15 (10.0%); P = .02], in unadjusted and adjusted analyses. Cardiac [8 (5.3%) vs 30 (20.0%); P < .001] and infective complications [4 (2.6%) vs 12 (8.0%); P = .04] were also fewer. LOS was unchanged. Frail patients in the postintervention group experienced significantly fewer geriatric syndromes including delirium. CONCLUSIONS AND IMPLICATIONS This is the first prospective study of inpatient geriatric comanagement for older vascular surgery patients. Reductions in hospital-acquired geriatric syndromes including delirium, and cardiac and infective complications were observed after implementing geriatric comanagement. These benefits were also demonstrated in the frail subgroup.
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Affiliation(s)
- Janani Thillainadesan
- Department of Geriatric Medicine, Concord Hospital, Concord, Sydney, Australia; Concord Clinical School, Faculty of Medicine and Health, The University of Sydney, Concord, Sydney, Australia; Center for Education and Research on Aging, and Aging and Alzheimers Institute, Concord, Sydney, Australia.
| | - Sarah J Aitken
- Concord Clinical School, Faculty of Medicine and Health, The University of Sydney, Concord, Sydney, Australia; Concord Institute of Academic Surgery, Vascular Surgery Department, Concord Hospital, Concord, Sydney, Australia; Department of Vascular Surgery, Concord Hospital, Concord, Sydney, Australia
| | - Sue R Monaro
- Department of Vascular Surgery, Concord Hospital, Concord, Sydney, Australia; Susan Wakil School of Nursing, The University of Sydney, Sydney, Australia
| | - John S Cullen
- Department of Geriatric Medicine, Concord Hospital, Concord, Sydney, Australia; Concord Clinical School, Faculty of Medicine and Health, The University of Sydney, Concord, Sydney, Australia; Center for Education and Research on Aging, and Aging and Alzheimers Institute, Concord, Sydney, Australia
| | - Richard Kerdic
- Department of Vascular Surgery, Concord Hospital, Concord, Sydney, Australia
| | - Sarah N Hilmer
- Kolling Institute of Medical Research, Sydney Medical School, University of Sydney and Royal North Shore Hospital, St Leonards, Sydney, Australia
| | - Vasi Naganathan
- Department of Geriatric Medicine, Concord Hospital, Concord, Sydney, Australia; Concord Clinical School, Faculty of Medicine and Health, The University of Sydney, Concord, Sydney, Australia; Center for Education and Research on Aging, and Aging and Alzheimers Institute, Concord, Sydney, Australia
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16
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Sutton EL, Kearney RS. What works? Interventions to reduce readmission after hip fracture: A rapid review of systematic reviews. Injury 2021; 52:1851-1860. [PMID: 33985752 DOI: 10.1016/j.injury.2021.04.049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 04/06/2021] [Accepted: 04/12/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Hip fracture is a common serious injury in older people and reducing readmission after hip fracture is a priority in many healthcare systems. Interventions which significantly reduce readmission after hip fracture have been identified and the aim of this review is to collate and summarise the efficacy of these interventions in one place. METHODS In a rapid review of systematic reviews one reviewer (ELS) searched the Ovid SP version of Medline and the Cochrane Database of Systematic Reviews. Titles and abstracts of 915 articles were reviewed. Nineteen systematic reviews were included. (ELS) used a data extraction sheet to capture data on interventions and their effect on readmission. A second reviewer (RK) verified data extraction in a random sample of four systematic reviews. Results were not meta-analysed. Odds and risk ratios are presented where available. RESULTS Three interventions significantly reduce readmission in elderly populations after hip fracture: personalised discharge planning, self-care and regional anaesthesia. Three interventions are not conclusively supported by evidence: Oral Nutritional Supplementation, integration of care, and case management. Two interventions do not affect readmission after hip fracture: Enhanced Recovery pathways and comprehensive geriatric assessment. CONCLUSIONS Three interventions are most effective at reducing readmissions in older people: discharge planning, self-care, and regional anaesthesia. Further work is needed to optimise interventions and ensure the most at-risk populations benefit from them, and complete development work on interventions (e.g. interventions to reduce loneliness) and intervention components (e.g. adapting self-care interventions for dementia patients) which have not been fully tested yet.
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Affiliation(s)
- E L Sutton
- Coventry University, School of Nursing, Midwifery and Health, Richard Crossman Building, CV1 5FB Coventry, England.
| | - R S Kearney
- University of Warwick, Clinical Trials Unit, CV4 7AL Coventry, England
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17
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Chen X, Lim JA, Zhou A, Thahir A. Currents concepts of the perioperative management of closed ankle fractures. J Perioper Pract 2021; 32:295-300. [PMID: 34190640 PMCID: PMC9619258 DOI: 10.1177/17504589211006018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Ankle fractures are common injuries that can result in substantial morbidity in the population. This review discusses the management of closed ankle fractures and outlines the recent evidence and guidelines on perioperative management. In general, a detailed history should be undertaken, followed by examination and imaging of the affected limb. Fixation is based on the AO principles of fracture management that aims towards restoring stability of the joint and reducing the risk of long-term complications. A multidisciplinary approach towards perioperative management is recommended in view of the increasing proportion of aging patients with significant comorbidities.
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Affiliation(s)
- Xiaoyu Chen
- Department of Trauma and Orthopaedics, Addenbrookes Major Trauma Unit, Cambridge University Hospitals, Cambridge, UK.,School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Jiang An Lim
- Department of Trauma and Orthopaedics, Addenbrookes Major Trauma Unit, Cambridge University Hospitals, Cambridge, UK.,School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Andrew Zhou
- Department of Trauma and Orthopaedics, Addenbrookes Major Trauma Unit, Cambridge University Hospitals, Cambridge, UK.,School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Azeem Thahir
- Department of Trauma and Orthopaedics, Addenbrookes Major Trauma Unit, Cambridge University Hospitals, Cambridge, UK
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Morrell AT, Kates SL, Lahaye LA, Layon DR, Patel NK, Scott MJ, Golladay GJ. Enhanced Recovery After Surgery: An Orthopedic Perspective. Arthroplast Today 2021; 9:98-100. [PMID: 34136612 PMCID: PMC8181632 DOI: 10.1016/j.artd.2021.04.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 04/21/2021] [Accepted: 04/25/2021] [Indexed: 12/14/2022] Open
Affiliation(s)
- Aidan T Morrell
- School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Stephen L Kates
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Laura A Lahaye
- Department of Anesthesiology, Virginia Commonwealth University, Richmond, VA, USA
| | - Daniel R Layon
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Nirav K Patel
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Michael J Scott
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Gregory J Golladay
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA, USA
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Strizich L, Kim CS. Improving Outcomes for Medically Complex Patients Undergoing Hip Fracture Surgery: It Will Take a Village. Jt Comm J Qual Patient Saf 2021; 47:205-206. [PMID: 33678526 DOI: 10.1016/j.jcjq.2021.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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20
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Fleury AM, McGowan B, Burstow MJ, Mudge AM. Sharing the helm: medical co‐management for the older surgical patient. ANZ J Surg 2020; 90:2357-2361. [DOI: 10.1111/ans.16347] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 08/13/2020] [Accepted: 09/11/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Aisling M. Fleury
- Perioperative Medicine Unit, Division of Surgery Logan Hospital Logan Queensland Australia
- Centre for Health Services Research PA Southside Clinical School, The University of Queensland Brisbane Queensland Australia
| | - Brian McGowan
- Department of Surgery Logan Hospital Logan Queensland Australia
| | - Matthew J. Burstow
- Department of Surgery Logan Hospital Logan Queensland Australia
- Department of Surgery Griffith University School of Medicine – Logan Campus Logan Queensland Australia
| | - Alison M. Mudge
- School of Clinical Medicine The University of Queensland Faculty of Medicine Brisbane Queensland Australia
- Internal Medicine and Aged Care Royal Brisbane and Women's Hospital Brisbane Queensland Australia
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21
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Kashikar A, Arya S. The Role Of Multidisciplinary Team Comanagement of the Surgical Patient-It Takes A Village. JAMA Netw Open 2020; 3:e204354. [PMID: 32369176 DOI: 10.1001/jamanetworkopen.2020.4354] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Aditi Kashikar
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, California
- Stanford-Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Shipra Arya
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, California
- Stanford-Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University School of Medicine, Stanford, California
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