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Giordano M, Casavant D, Flores Cano JC, Rempel G, Dorste A, Graham RJ, Quates SK, Belthur MV, Bastianelli LC, Sewell TB, Zamkoff J, Mauskar S, Mariani J, Trost MJ, Simpson B, Stringfellow I, Berry JG. Perioperative Health Interventions in Children With Chronic Neuromuscular Conditions Undergoing Major Musculoskeletal Surgery: A Scoping Review. Hosp Pediatr 2024; 14:e281-e291. [PMID: 38726564 DOI: 10.1542/hpeds.2021-006187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 02/06/2024] [Accepted: 02/09/2024] [Indexed: 06/02/2024]
Abstract
BACKGROUND AND OBJECTIVES Children with chronic neuromuscular conditions (CCNMC) have many coexisting conditions and often require musculoskeletal surgery for progressive neuromuscular scoliosis or hip dysplasia. Adequate perioperative optimization may decrease adverse perioperative outcomes. The purpose of this scoping review was to allow us to assess associations of perioperative health interventions (POHI) with perioperative outcomes in CCNMC. METHODS Eligible articles included those published from January 1, 2000 through March 1, 2022 in which the authors evaluated the impact of POHI on perioperative outcomes in CCNMC undergoing major musculoskeletal surgery. Multiple databases, including PubMed, Embase, Cumulative Index of Nursing and Allied Health Literature, Web of Science, the Cochrane Library, Google Scholar, and ClinicalTrials.gov, were searched by using controlled vocabulary terms and relevant natural language keywords. Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines were used to perform the review. A risk of bias assessment for included studies was performed by using the Risk of Bias in Non-randomized Studies of Interventions tool. RESULTS A total of 7013 unique articles were initially identified, of which 6286 (89.6%) were excluded after abstract review. The remaining 727 articles' full texts were then reviewed for eligibility, resulting in the exclusion of 709 (97.5%) articles. Ultimately, 18 articles were retained for final analysis. The authors of these studies reported various impacts of POHI on perioperative outcomes, including postoperative complications, hospital length of stay, and hospitalization costs. Because of the heterogeneity of interventions and outcome measures, meta-analyses with pooled data were not feasible. CONCLUSIONS The findings reveal various impacts of POHI in CCNMC undergoing major musculoskeletal surgery. Multicenter prospective studies are needed to better address the overall impact of specific interventions on perioperative outcomes in CCNMC.
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Affiliation(s)
- Mirna Giordano
- Department of Pediatrics, Division of Critical Care and Hospital Medicine, Columbia University, New York, New York
| | | | - Juan Carlos Flores Cano
- Division of Pediatrics, Pontificia Universidad Catolica de Chile, Hospital Dr. Sotero del Rio, Santiago, Chile
| | - Gina Rempel
- Nutrition Support and Complex Care, Department of Pediatrics and Children Health, University of Manitoba, Winnipeg, Canada
| | - Anna Dorste
- Boston Children's Hospital Medical Library, Boston, Massachusetts
| | | | - Sara K Quates
- Medical College of Wisconsin, Children's Wisconsin Hospital, Milwaukee, Wisconsin
| | - Mohan V Belthur
- Division of Pediatrics, University of Arizona College of Medicine Phoenix, Phoenix, Arizona
| | - Lucia C Bastianelli
- Cerebral Palsy and Spasticity Center, Boston Children's Hospital, Boston, Massachusetts
| | - Taylor B Sewell
- Department of Pediatrics, Division of Critical Care and Hospital Medicine, Columbia University, New York, New York
| | - Jason Zamkoff
- Department of Pediatrics, Children's Hospital of Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | | | - Juliana Mariani
- Medical Critical Care, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Margaret J Trost
- Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Blair Simpson
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
| | - Isabel Stringfellow
- General Pediatrics
- Cerebral Palsy and Spasticity Center, Boston Children's Hospital, Boston, Massachusetts
| | - Jay G Berry
- General Pediatrics
- Cerebral Palsy and Spasticity Center, Boston Children's Hospital, Boston, Massachusetts
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Metter R, Johnson A, Burden M. Optimizing Hospitalist Co-Management for Improved Patient, Workforce, and Organizational Outcomes. Jt Comm J Qual Patient Saf 2024; 50:305-307. [PMID: 38553379 DOI: 10.1016/j.jcjq.2024.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2024]
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3
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Rosa PRM, Spagnól MF, Rothlisberger L, Gelain MAS, de Brida MS, Teixeira C. Internal medicine consultation for high-risk surgical patients: reflection on hospital mortality and readmission rates in a low-income country. REVISTA DA ASSOCIACAO MEDICA BRASILEIRA (1992) 2023; 69:e20230468. [PMID: 37909615 PMCID: PMC10610760 DOI: 10.1590/1806-9282.20230468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 08/03/2023] [Indexed: 11/03/2023]
Abstract
OBJECTIVE The objective of this study was to assess the impact of internal medicine consultation on mortality, 30-day readmission, and length of stay in surgical patients. METHODS This is a retrospective descriptive study developed in a public Brazilian teaching hospital with 850 beds. RESULTS A total of 70,245 patients were admitted from 2010 to 2018 to the surgery departments. The main outcomes measured were patients' mortality, 30-day readmission, and length of stay. Mortality of high-risk patients was lower when followed by internal medicine consultation: patients with ASA≥3 (RR 0.89 [95% confidence interval (95%CI) 0.80-0.99], p=0.02), patients with ASA≥3 plus≥65 years (RR 0.88 [95%CI 0.78-0.99], p=0.04), patients with ASA≥3 plus high-risk surgery (RR 0.86 [95%CI 0.77-0.97], p=0.01), and patients with ASA≥4 plus age ≥65 years (RR 0.83 [95%CI 0.72-0.96], p=0.01). The 30-day readmission of high-risk patients was lower when followed by internal medicine consultation: patients with ≥65 years (RR 0.57 [95%CI 0.37-0.89], p=0.01) and patients with high-risk surgery (RR 0.63 [95%CI 0.46-0.57], p=0.005). The Poisson multivariate regression with adjustment in variances showed that all the variables (namely, age, ASA, morbidity index, surgery risk, and internal medicine consultation) were associated with higher mortality of patients; however, internal medicine consultation was associated with a reduction of mortality in high-risk patients (RR 0.72 [95%CI 0.65-0.84], p=0.02) and an increase of mortality in low-risk patients (RR 1.55 [95%CI 1.31-1.67], p=0.01). CONCLUSION High-risk surgical patients may benefit from perioperative internal medicine consultations, which probably decrease hospital mortality and 30-day hospital readmission.
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Affiliation(s)
| | | | | | | | | | - Cassiano Teixeira
- Universidade Federal de Ciências da Saúde de Porto Alegre, Medical School, Internal Medicine Department – Porto Alegre (RS), Brazil
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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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Rogers NG, Carrillo-Marquez M, Carlisle A, Sanders CD, Burge L. Friends Not Foes: Optimizing Collaboration with Subspecialists. Orthop Clin North Am 2023; 54:277-285. [PMID: 37271556 DOI: 10.1016/j.ocl.2023.02.002] [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: 06/06/2023]
Abstract
Pediatric orthopedic patients can be complex to manage. As orthopedists plan for possible surgical interventions, consultation with pediatric subspecialists will be necessary. This article discusses the considerations an orthopedist should make when deciding on the timing and the appropriateness of consultation-both preoperatively and perioperatively. Consultation before surgical intervention will especially be useful if the subspecialist will be collaborating in the management of the condition postoperatively (whether inpatient or outpatient). Clear and early consultation in both written and verbal format will facilitate quality and expedite the patient's care.
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Affiliation(s)
- Nathaniel G Rogers
- Division of Pediatric Hospital Medicine, University of Tennessee Health Science Center, 49 North Dunlap Street, Memphis, TN 38103, USA.
| | - Maria Carrillo-Marquez
- Division of Infectious Diseases, University of Tennessee Health Science Center, 49 North Dunlap Street, Memphis, TN 38103, USA
| | - Annette Carlisle
- Division of Allergy & Immunology, University of Tennessee Health Science Center, 49 North Dunlap Street, Memphis, TN 38103, USA
| | - Catherine D Sanders
- Division of Pulmonology, University of Tennessee Health Science Center, 49 North Dunlap Street, Memphis, TN 38103, USA
| | - Lauren Burge
- Division of Child Abuse, University of Tennessee Health Science Center, 49 North Dunlap Street, Memphis, TN 38103, USA
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Zhang NJ, Sinvani L, Leung TM, Qiu M, Meyer CL, Sharma A, Kurian LM, Bank MA, Kast CL. A Geriatrics-Focused Hospitalist Trauma Comanagement Program Improves Quality of Care for Older Adults. Am J Med Qual 2022; 37:214-220. [PMID: 34433177 DOI: 10.1097/jmq.0000000000000018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This study aimed to determine whether a geriatrics-focused hospitalist trauma comanagement program improves quality of care. A pre-/post-implementation study compared older adult trauma patients who were comanaged by a hospitalist with those prior to comanagement at a level 1 trauma center. One-to-one propensity score matching was performed based on age, gender, Injury Severity Score, comorbidity index, and critical illness on admission. Outcomes included orders for geriatrics-focused quality indicators, as well as hospital mortality and length of stay. Wilcoxon rank-sum test (continuous variables) and chi-square or Fisher exact test (categorical variables) were used to assess differences. Propensity score matching resulted in 290 matched pairs. The intervention group had decreased use of restraints (P = 0.04) and acetaminophen (P = 0.01), and earlier physical therapy (P = 0.01). Three patients died in the intervention group compared with 14 in the control (P = 0.0068). This study highlights that a geriatrics-focused hospitalist trauma comanagement program improves quality of care.
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Affiliation(s)
- Nasen J Zhang
- Division of Hospital Medicine, Department of Medicine, Northwell Health, Manhasset, NY
| | - Liron Sinvani
- Division of Hospital Medicine, Department of Medicine, Northwell Health, Manhasset, NY
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY
| | - Tung Ming Leung
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY
| | - Michael Qiu
- Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY
| | - Cristy L Meyer
- Division of Trauma and Critical Care Surgery, Northwell Health, Manhasset, NY
| | - Ankita Sharma
- Division of Hospital Medicine, Department of Medicine, Northwell Health, Manhasset, NY
| | - Linda M Kurian
- Division of Hospital Medicine, Department of Medicine, Northwell Health, Manhasset, NY
| | - Matthew A Bank
- Division of Trauma and Critical Care Surgery, Northwell Health, Manhasset, NY
| | - Charles L Kast
- Division of Hospital Medicine, Department of Medicine, Northwell Health, Manhasset, NY
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Para O, Caruso L, Fedi G, Maddaluni L, Nozzoli C. Medical and surgical co-management: is time ripe? Intern Emerg Med 2022; 17:935-936. [PMID: 33837905 DOI: 10.1007/s11739-021-02726-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Accepted: 03/27/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Ombretta Para
- Internal Medicine 1, Careggi University Hospital, Florence, Italy
| | - Lorenzo Caruso
- Internal Medicine 1, Careggi University Hospital, Florence, Italy.
| | - Giacomo Fedi
- Internal Medicine 1, Careggi University Hospital, Florence, Italy
| | - Lucia Maddaluni
- Internal Medicine 1, Careggi University Hospital, Florence, Italy
| | - Carlo Nozzoli
- Internal Medicine 1, Careggi University Hospital, Florence, Italy
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8
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Melis LCB, Linkens AEMJH, Antonides-Göbbels S, Pijls N, Ten Broeke RHM, Sipers W, Spaetgens B. Perceptions of Medical and Surgical Health Care Providers Toward Orthogeriatric Care Delivery: An Exploratory Survey. J Am Med Dir Assoc 2021; 23:698-700. [PMID: 34968421 DOI: 10.1016/j.jamda.2021.11.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 11/23/2021] [Accepted: 11/23/2021] [Indexed: 10/19/2022]
Affiliation(s)
- Laura C B Melis
- Department of Orthopedic Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Aimée E M J H Linkens
- Section Geriatric Medicine, Division of General Internal Medicine, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Sanne Antonides-Göbbels
- Section Geriatric Medicine, Division of General Internal Medicine, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Noor Pijls
- Section Geriatric Medicine, Division of General Internal Medicine, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - René H M Ten Broeke
- Department of Orthopedic Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands; Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands
| | - Walther Sipers
- Department of Geriatric Medicine, Zuyderland Medical Centre, Sittard-Geleen, the Netherlands
| | - Bart Spaetgens
- Section Geriatric Medicine, Division of General Internal Medicine, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands
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9
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Schaffer AC, Yu-Moe CW, Babayan A, Wachter RM, Einbinder JS. Rates and Characteristics of Medical Malpractice Claims Against Hospitalists. J Hosp Med 2021; 16:390-396. [PMID: 34197302 DOI: 10.12788/jhm.3557] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 10/26/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Hospitalists practice in high-stakes and litigious settings. However, little data exist about the malpractice claims risk faced by hospitalists. OBJECTIVE To characterize the rates and characteristics of malpractice claims against hospitalists. DESIGN, SETTING, AND PARTICIPANTS An analysis was performed of malpractice claims against hospitalists, as well as against select other specialties, using data from a malpractice claims database that includes approximately 31% of US malpractice claims. MAIN OUTCOMES AND MEASURES For malpractice claims against hospitalists (n = 1,216) and comparator specialties (n = 18,644): claims rates (using a data subset), percentage of claims paid, median indemnity payment amounts, allegation types, and injury severity. RESULTS Hospitalists had an annual malpractice claims rate of 1.95 claims per 100 physician-years, similar to that of nonhospitalist general internal medicine physicians (1.92 claims per 100 physician-years), and significantly greater than that of internal medicine subspecialists (1.30 claims per 100 physician-years) (P < .001). Claims rates for hospitalists nonsignificantly increased during the study period (2009-2018), whereas claims rates for four of the five other specialties examined significantly decreased over this period. The median indemnity payment for hospitalist claims was $231,454 (interquartile range, $100,000-$503,015), significantly higher than the amounts for all the other specialties except neurosurgery. The greatest predictor of a hospitalist case closing with payment (compared with no payment) was an error in clinical judgment as a contributing factor, with an adjusted odds ratio of 5.01 (95% CI, 3.37-7.45). CONCLUSION During the study period, hospitalist claims rates did not drop, whereas they fell for other specialties. Hospitalists' claims had relatively high injury severity and median indemnity payment amounts. The malpractice environment for hospitalists is becoming less favorable.
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Affiliation(s)
- Adam C Schaffer
- CRICO/Risk Management Foundation of the Harvard Medical Institutions, Boston, Massachusetts
- Brigham and Women's Hospital, Boston, Massachusetts
| | - Chihwen Winnie Yu-Moe
- CRICO/Risk Management Foundation of the Harvard Medical Institutions, Boston, Massachusetts
| | - Astrid Babayan
- CRICO/Risk Management Foundation of the Harvard Medical Institutions, Boston, Massachusetts
| | - Robert M Wachter
- University of California, San Francisco, San Francisco, California
| | - Jonathan S Einbinder
- CRICO/Risk Management Foundation of the Harvard Medical Institutions, Boston, Massachusetts
- Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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10
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Luu BC, Davis MJ, Raj S, Abu-Ghname A, Buchanan EP. Cost-effectiveness of surgical comanagement: A systematic review. Surgeon 2021; 19:119-127. [DOI: 10.1016/j.surge.2020.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 04/01/2020] [Indexed: 12/19/2022]
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11
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Reza JA, Steve Eubanks W, de la Fuente SG. Clinical and Financial Implications of Consulting Physicians in the Management of Surgical Patients. Am Surg 2020; 88:578-586. [PMID: 33291943 DOI: 10.1177/0003134820952439] [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: 11/16/2022]
Abstract
BACKGROUND The present study was designed to evaluate the immediate consequences that the number of consulting physicians has on length of stay (LOS), in-hospital mortality, 30-day readmission rates, direct health care costs, and contribution margins. METHODS A retrospective review of administrative databases for the years 2013 and 2014 was performed at the Florida Hospital Adventist Healthcare System. RESULTS 11 274 patients were included in the analysis. Total and variable costs increased by $1347 and $592, respectively, with each consulting physician service per patient. The contribution margin decreased by $354 per patient/consulting physician. Each consulting physician increased LOS by .72 days and increased odds ratio of mortality and 30-day readmission by 5% and 3%, respectively. CONCLUSIONS Our research suggests that each consulting physician added to the care of an individual surgical patient negatively affected LOS, readmission rates, in-hospital mortality, and costs.
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Affiliation(s)
- Joseph A Reza
- Department of Surgery, AdventHealth Orlando, FL, USA
| | - W Steve Eubanks
- Department of Surgery, AdventHealth Orlando, FL, USA.,University of Central Florida, Orlando, FL, USA
| | - Sebastian G de la Fuente
- Department of Surgery, AdventHealth Orlando, FL, USA.,University of Central Florida, Orlando, FL, USA
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12
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Vincent C, Cram P. Surgical Comanagement for Hip Fracture: Time for a Randomized Trial. J Hosp Med 2020; 15:510-511. [PMID: 32804616 PMCID: PMC7518137 DOI: 10.12788/jhm.3415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 03/24/2020] [Indexed: 11/20/2022]
Affiliation(s)
- Corita Vincent
- Department of Medicine, University of Toronto, Toronto,
Canada
| | - Peter Cram
- Department of Medicine, University of Toronto, Toronto,
Canada
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto,
Canada
- Division of General Internal Medicine and Geriatrics, Sinai Health System, Toronto,
Canada
- Corresponding Author: Peter Cram, MD, MBA; ; Telephone: 647-767-5508; Twitter: @pmcram
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Shaw M, Pelecanos AM, Mudge AM. Evaluation of Internal Medicine Physician or Multidisciplinary Team Comanagement of Surgical Patients and Clinical Outcomes: A Systematic Review and Meta-analysis. JAMA Netw Open 2020; 3:e204088. [PMID: 32369179 PMCID: PMC7201311 DOI: 10.1001/jamanetworkopen.2020.4088] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 03/03/2020] [Indexed: 01/29/2023] Open
Abstract
Importance Older patients who undergo surgery may benefit from geriatrician comanagement. It is unclear whether other internal medicine (IM) physician involvement improves outcomes for adults who undergo surgery. Objective To evaluate the association of IM physician involvement with clinical and health system outcomes compared with usual surgical care among adults who undergo surgery. Data Sources MEDLINE, Embase, CINAHL, and CENTRAL databases were searched for studies published in English from database inception to April 2, 2019. Study Selection Prospective randomized or nonrandomized clinical studies comparing IM physician consultation or comanagement with usual surgical care were selected by consensus of 2 reviewers. Data Extraction and Synthesis Data were extracted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline by 2 authors independently. Intervention characteristics were described using existing indicators. Risk of bias was assessed using Risk of Bias 2.0 and Risk of Bias in Nonrandomized Studies of Interventions tools. Studies were pooled when appropriate in meta-analysis using random-effects models. Prespecified subgroups included IM physician-only vs multidisciplinary team interventions and patients undergoing elective vs emergency procedures. Main Outcomes and Measures The prespecified primary outcome was length of stay; other outcomes included 30-day readmissions, inpatient mortality, medical complications, functional outcomes, and costs. Results Of 6027 records screened, 14 studies (with 1 randomized clinical trial) involving 35 800 patients (13 142 [36.7%] in intervention groups) were eligible for inclusion. Interventions varied substantially among studies and settings; most interventions described comanagement by a hospitalist or internist; 7 (50%) included a multidisciplinary team, and 9 (64%) studied predominantly patients who had elective procedures. Risk of bias in 10 studies (71%) was serious. Meta-analysis showed no significant association with length of stay (mean difference, -1.02 days; 95% CI, -2.09 to 0.04 days; P = .06) or mortality (odds ratio, 0.79; 95% CI, 0.56 to 1.11; P = .18), but multidisciplinary team involvement was associated with significant reduction in length of stay (mean difference, -2.03 days; 95% CI, -4.05 to -0.01 days; P = .05) and mortality (odds ratio, 0.67; 95% CI, 0.51 to 0.88; P = .004). There was no difference in 30-day readmissions (odds ratio, 0.89; 95% CI, 0.68 to 1.16; P = .39). Data could not be pooled for complications or costs. Only 1 study (7%) reported functional outcomes. Conclusions and Relevance The findings of this study suggest that IM physician comanagement that includes multidisciplinary team involvement may be associated with reduced length of stay and mortality in adults undergoing surgery. Evidence was low quality, and well-designed prospective studies are still needed.
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Affiliation(s)
- Margaret Shaw
- Royal Brisbane and Women’s Hospital, Herston, Queensland, Australia
| | - Anita M. Pelecanos
- QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - Alison M. Mudge
- Royal Brisbane and Women’s Hospital, Herston, Queensland, Australia
- University of Queensland School of Clinical Medicine, Brisbane, Queensland, Australia
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Abstract
Veterinary medicine has traditionally functioned as an art and a science, that is, as knowledge of general principles and knowledge of, and relationship with, the individual animal and their caregiver. With the advent of increasing specialization, this intimate knowledge of the individual is being lost. This has great ramifications for diagnosis and treatment. Knowing the particular personality and tendencies of the patient helps differentiate between behavioral issues and fully medical issues. Excessive "scientization" in veterinary medicine needs to be addressed in veterinary medical education.
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Wang ES, Moreland C, Shoffeitt M, Leykum LK. Who Consults Us and Why? An Evaluation of Medicine Consult/Comanagement Services at Academic Medical Centers. J Hosp Med 2018; 13:840-843. [PMID: 30156582 DOI: 10.12788/jhm.2996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Although general medicine consultation is an integral component of inpatient medical care and a requirement of internal medicine training, little is known about current consultative practice. We used a cross-sectional, prospective survey design to examine current practices at 11 academic medical centers over four two-week periods from July 2014 through July 2015. Out of 11 consult services, four had comanagement agreements with surgical services, primarily with orthopedic surgery. We collected data regarding 1,264 consultation requests. Most requests (82.2%) originated from surgical services, with most requests originating from either orthopedic surgery (44.4%) or neurosurgery (11.6%). The most common reason for consultation at sites with a consult and comanagement service was medical management/ comanagement (23.3%) and at sites with a consultonly service was preoperative evaluation (16.4%). On average, consultants addressed more than two reasons per encounter. Many of these reasons were unidentified by the consulting service. Learners on these services should perform comprehensive evaluations to identify potentially unidentified issues.
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Affiliation(s)
- Emily S Wang
- South Texas Veterans Health Care System, Medicine Service, San Antonio, Texas, USA.
- Department of Medicine, Division of General and Hospital Medicine, University of Texas Health San Antonio, San Antonio, Texas, USA
| | - Christopher Moreland
- Department of Medicine, Division of General and Hospital Medicine, University of Texas Health San Antonio, San Antonio, Texas, USA
| | - Michael Shoffeitt
- Department of Medicine, Division of General and Hospital Medicine, University of Texas Health San Antonio, San Antonio, Texas, USA
| | - Luci K Leykum
- South Texas Veterans Health Care System, Medicine Service, San Antonio, Texas, USA
- Department of Medicine, Division of General and Hospital Medicine, University of Texas Health San Antonio, San Antonio, Texas, USA
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Rappaport DI, Rosenberg RE, Shaughnessy EE, Schaffzin JK, O'Connor KM, Melwani A, McLeod LM. Pediatric hospitalist comanagement of surgical patients: structural, quality, and financial considerations. J Hosp Med 2014; 9:737-42. [PMID: 25283766 DOI: 10.1002/jhm.2266] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Revised: 09/08/2014] [Accepted: 09/13/2014] [Indexed: 11/11/2022]
Abstract
Comanagement of surgical patients is occurring more commonly among adult and pediatric patients. These systems of care can vary according to institution type, comanagement structure, and type of patient. Comanagement can impact quality, safety, and costs of care. We review these implications for pediatric surgical patients.
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Affiliation(s)
- David I Rappaport
- Nemours/AI DuPont Hospital for Children, General Pediatrics, Wilmington, Delaware; Kimmel College of Medicine at Thomas Jefferson University, Philadelphia, Pennsylvania
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Schaffzin JK, Simon TD. Pediatric hospital medicine role in the comanagement of the hospitalized surgical patient. Pediatr Clin North Am 2014; 61:653-61. [PMID: 25084714 PMCID: PMC4119591 DOI: 10.1016/j.pcl.2014.04.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Medical comanagement of surgical patients by pediatric hospital medicine providers has become increasingly common. Subjectively, the comanagement model is superior to more traditional consultative models because of the anticipatory preventive care and coordination hospitalists provide to patients and hospital colleagues. Although some studies have demonstrated the value of the comanagement model in adults and children, others have failed to do so. The coming years are both exciting and challenging for this emerging field as it attempts to sustain its early progress and define its future in pediatric hospital medicine.
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Affiliation(s)
- Joshua K. Schaffzin
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Tamara D. Simon
- Division of Hospital Medicine, Department of Pediatrics, University of Washington and Seattle Children’s Hospital, Seattle, Washington
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Trends in healthcare and the role of the anesthesiologist in the perioperative surgical home – the US perspective. Curr Opin Anaesthesiol 2014; 27:371-6. [DOI: 10.1097/aco.0000000000000064] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Co-management between hospitalist and hepatologist improves the quality of care of inpatients with chronic liver disease. J Clin Gastroenterol 2014; 48:e30-6. [PMID: 24100752 DOI: 10.1097/mcg.0b013e3182a87f70] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND GOALS Our institution shifted the care of patients with chronic liver disease (CLD) from Internal Medicine faculty, house staff, and consulting hepatology service to a co-managed unit staffed by academic hospitalists and hepatologists. The effect of co-management between hospitalists and hepatologists on the care of patients hospitalized with complications of CLD such as spontaneous bacterial peritonitis (SBP) is unknown. STUDY A retrospective chart review of 56 adult patients admitted with CLD and SBP from July 1, 2004 to June 30, 2010 was performed. Adherence rates to current management guidelines were measured along with costs and outcomes of care. RESULTS Patients admitted under the 2 models of care were similar; however, they consistently underwent paracentesis within 24 hours (100% vs. 79%, P=0.013), had appropriate avoidance of fresh-frozen plasma use (75% vs. 43%, P=0.05), received albumin (97% vs. 65%, P=0.002), and were discharged on SBP prophylaxis (91% vs. 37%, P<0.001) under the co-managed model compared with the conventional model. Costs of care were similar between the 2 groups. We note a trend toward improved outcomes of care under the co-management model as measured by transfer rates to the intensive care unit, inpatient mortality, 30-day readmission, and mortality rates. CONCLUSIONS These results support co-management between hospitalists and hepatologists as a superior model of care for hospitalized patients with SBP. Furthermore, this study adds to the growing literature indicating that efforts are needed to improve the quality of care delivered to CLD patients.
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Story DA, Shelton A, Jones D, Heland M, Belomo R. Audit of co-management and critical care outreach for high risk postoperative patients (The POST audit). Anaesth Intensive Care 2014; 41:793-8. [PMID: 24180722 DOI: 10.1177/0310057x1304100616] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Co-management and critical care outreach for high risk surgical patients have been proposed to decrease postoperative complications and mortality. We proposed that a clinical project with postoperative comanagement and critical care outreach, the Post Operative Surveillance Team: (POST), would be associated with decreased hospital length of stay. We conducted a retrospective before (control group) and after (POST group) audit of this hospital program. POST was staffed for four months in 2010 by two intensive care nurses and two senior registrars who conducted daily ward rounds for the first five postoperative days on high risk patients undergoing inpatient general or urological surgery. The primary endpoint was length of hospital stay and secondary endpoints were Medical Emergency Team (MET) calls, cardiac arrests and in-hospital mortality. There were 194 patients in the POST group and 1,185 in the control group. The length of stay in the POST group, median nine days (Inter-quartile range [IQR]: 5 to 17 days), was longer than the control group, median seven days (IQR: 4 to 13 days): difference two days longer (95.0% confidence interval [95.0% CI]: 1 to 3 days longer, P <0.001). There were no important differences in the proportion of patients having MET calls (16.0% POST versus. 13% control (P=0.25)) or mortality (2.1% POST versus 2.8% Control (P=0.82)). Our audit found that the POST service was not associated with reduced length of stay. Models of co-management, different to POST, or with different performance metrics, could be tested.
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Affiliation(s)
- D A Story
- Division of Surgery and Departments of Intensive Care and Anaesthesia, Austin Health; and Anaesthesia, Perioperative and Pain Medicine Unit, Melbourne Medical School, University of Melbourne, Melbourne, Victoria
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Simon TD. How best to design surgical comanagement services for pediatric surgical patients? Hosp Pediatr 2013; 3:242-3. [PMID: 24313093 DOI: 10.1542/hpeds.2013-0033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Tamara D Simon
- Department of Pediatrics University of Washington/Seattle Children's Hospital, Seattle, Washington 98101, USA.
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Rappaport DI, Cerra S, Hossain J, Sharif I, Pressel DM. Pediatric hospitalist preoperative evaluation of children with neuromuscular scoliosis. J Hosp Med 2013; 8:684-8. [PMID: 24249030 DOI: 10.1002/jhm.2101] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Revised: 09/25/2013] [Accepted: 09/30/2013] [Indexed: 11/07/2022]
Abstract
WHAT'S NEW This is the first study of a pediatric hospitalist preoperative clinic. Pediatric hospitalists frequently make significant recommendations for patients with neuromuscular scoliosis prior to spinal surgery, especially those with medical complexity. Certain clinical criteria are statistically significantly associated with a hospitalist making a preoperative recommendation. OBJECTIVE To assess (1) how frequently pediatric hospitalists make recommendations when evaluating preoperative neuromuscular scoliosis patients in anticipation of spinal fusion surgery and (2) evaluate if any clinical characteristics are associated with a higher likelihood of hospitalists doing so. METHODS We performed a case series study using retrospective chart review of 214 patients scheduled for spinal fusion surgery for neuromuscular scoliosis from November 2009 through September 2012. RESULTS We analyzed data for 214 patients aged 1 to 20 years (median, 13 years), of whom 155 (72%) received at least 1 specific preoperative recommendation, whereas 59 patients (28%) were cleared for surgery without specific recommendations. Underlying diagnosis (P = 0.024), nonambulatory status (odds ratio [OR]: 2.02, 95% confidence interval [CI]: 1.09-3.74), and increased number of preoperative medications (OR: 1.19, 95% CI: 1.06-1.34) were statistically significantly associated with an increased rate of receiving preoperative recommendations from the hospitalist. Comorbidities such as seizure disorder (OR: 2.68, 95% CI: 1.29-5.57) and gastrointestinal conditions (OR: 3.35, 95% CI: 1.74-6.45) were also statistically significantly associated with specific presurgical recommendations being made by the pediatric hospitalist. CONCLUSION A pediatric hospitalist preoperative program for children with neuromuscular scoliosis in anticipation of spinal fusion surgery is associated with a high rate of recommendations being made, especially in children with certain clinical characteristics.
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Affiliation(s)
- David I Rappaport
- Department of General Pediatrics, Nemours/AI duPont Hospital, Wilmington, Delaware; Jefferson Medical College, Philadelphia, Pennsylvania
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Roberts DL, Cannon KJ, Wellik KE, Wu Q, Budavari AI. Burnout in inpatient-based versus outpatient-based physicians: a systematic review and meta-analysis. J Hosp Med 2013; 8:653-64. [PMID: 24167011 DOI: 10.1002/jhm.2093] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Revised: 09/05/2013] [Accepted: 09/13/2013] [Indexed: 11/09/2022]
Abstract
BACKGROUND Burnout is a syndrome affecting the entirety of work life and characterized by cynicism, detachment, and inefficacy. Despite longstanding concerns about burnout in hospital medicine, few data about burnout in hospitalists have been published. PURPOSE A systematic review of the literature on burnout in inpatient-based and outpatient-based physicians worldwide was undertaken to determine whether inpatient physicians experience more burnout than outpatient physicians. DATA SOURCES Five medical databases were searched for relevant terms with no language restrictions. Authors were contacted for unpublished data and clarification of the practice location of study subjects. STUDY SELECTION Two investigators independently reviewed each article. Included studies provided a measure of burnout in inpatient and/or outpatient nontrainee physicians. DATA EXTRACTION Fifty-four studies met inclusion criteria, 15 of which provided direct comparisons of inpatient and outpatient physicians. Twenty-eight studies used the same burnout measure and therefore were amenable to statistical analysis. DATA SYNTHESIS Outpatient physicians reported more emotional exhaustion than inpatient physicians. No statistically significant differences in depersonalization or personal accomplishment were found. Further comparisons were limited by the heterogeneity of instruments used to measure burnout and the lack of available information about practice location in many studies. CONCLUSIONS The existing literature does not support the widely held belief that burnout is more frequent in hospitalists than outpatient physicians. Better comparative studies of hospitalist burnout are needed.
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Affiliation(s)
- Daniel L Roberts
- Division of Hospital Internal Medicine, Mayo Clinic Hospital, Phoenix, Arizona
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Rappaport DI, Adelizzi-Delany J, Rogers KJ, Jones CE, Petrini ME, Chaplinski K, Ostasewski P, Sharif I, Pressel DM. Outcomes and costs associated with hospitalist comanagement of medically complex children undergoing spinal fusion surgery. Hosp Pediatr 2013; 3:233-241. [PMID: 24313092 DOI: 10.1542/hpeds.2012-0066] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
OBJECTIVE The goal of this study was to assess outcomes and costs associated with hospitalist comanagement of medically complex children undergoing spinal fusion surgery for neuromuscular scoliosis. METHODS A hospitalist comanagement program was implemented at a children's hospital. We conducted a retrospective case series study of patients during 2003-2008 to compare clinical and cost outcomes for 87 preimplementation patients, 40 patients during a partially implemented program, and 80 patients during a fully implemented program. RESULTS When compared with preimplementation patients, full implementation program patients did not demonstrate a statistically significant difference in median length of stay on the medical/surgical unit after transfer from the PICU (median: 6 vs 8 days; P = .07). Patients in the full implementation group received fewer days of parenteral nutrition (median: 0 vs 6 days; P = .0006) and had fewer planned and unplanned laboratory studies on the inpatient unit. There was no statistically significant change in returns to the operating room (P = .08 between preimplementation and full implementation), other complications, or 30-day readmissions. Median hospital costs increased from preimplementation ($59372) to partial implementation ($89302) and remained elevated during full implementation ($81 651) compared with preimplementation (P = .004). Mean physician costs followed a similar trajectory from preimplementation ($18425) to partial implementation ($24101) to full implementation ($22578; P = .0006 [versus preimplementation]). CONCLUSIONS A hospitalist comanagement program can significantly affect the care of medically complex children undergoing spinal fusion surgery. Initial program costs may increase.
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Affiliation(s)
- David I Rappaport
- Department of General Pediatrics, 1600 Rockland Rd, Alfred I. duPont Hospital for Children, Wilmington, DE 19803, USA.
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Comanagement: Who's in Charge? AORN J 2013; 97:764, 678. [DOI: 10.1016/j.aorn.2013.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Accepted: 03/19/2013] [Indexed: 10/26/2022]
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Vetter TR, Goeddel LA, Boudreaux AM, Hunt TR, Jones KA, Pittet JF. The Perioperative Surgical Home: how can it make the case so everyone wins? BMC Anesthesiol 2013; 13:6. [PMID: 23497277 PMCID: PMC3605191 DOI: 10.1186/1471-2253-13-6] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2012] [Accepted: 03/08/2013] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Varied and fragmented care plans undertaken by different practitioners currently expose surgical patients to lapses in expected care, increase the chance for operational mistakes and accidents, and often result in unnecessary care. The Perioperative Surgical Home has thus been proposed by the American Society of Anesthesiologists and other stakeholders as an innovative, patient-centered, surgical continuity of care model that incorporates shared decision making. Topics central to the debate about an anesthesiology-based Perioperative Surgical Home include: holding the gains made in anesthesia-related patient safety; impacting surgical morbidity and mortality, including failure-to-rescue; achieving healthcare outcome metrics; assimilating comparative effectiveness research into the model; establishing necessary audit and data collection; a comparison with the hospitalist model of perioperative care; the perspective of the surgeon; the benefits of the Perioperative Surgical Home to the specialty of anesthesiology; and its associated healthcare economic advantages. DISCUSSION Improving surgical morbidity and mortality mandates a more comprehensive and integrated approach to the management of surgical patients. In their expanded capacity as the surgical patient's "perioperativist," anesthesiologists can play a key role in compliance with broader set of process measures, thus becoming a more vital and valuable provider from the patient, administrator, and payer perspective. The robust perioperative databases created within the Perioperative Surgical Home present new opportunities for health services and population-level research. The Perioperative Surgical Home is not intended to replace the surgeon's patient care responsibility, but rather leverage the abilities of the entire perioperative care team in the service of the patient. To achieve this goal, it will be necessary to expand the core knowledge, skills, and experience of anesthesiologists. Anesthesiologists will need to view becoming perioperative physicians as an expansion of the specialty, rather than an abdication of their traditional intraoperative role. The Perioperative Surgical Home will need to create strategic added value for a health system and payers. This added value will strengthen the position of anesthesiologists as they navigate and negotiate in the face of finite, if not decreasing fiscal resources. SUMMARY Broadening the anesthesiologist's scope of practice via the Perioperative Surgical Home may promote standardization and improve clinical outcomes and decrease resource utilization by providing greater patient-centered continuity of care throughout the preoperative, intraoperative, and postoperative periods.
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Affiliation(s)
- Thomas R Vetter
- Department of Anesthesiology, University of Alabama School of Medicine, JT862, 619 19th Street South, Birmingham, AL, 35249-6810, USA
| | - Lee A Goeddel
- Department of Anesthesiology, University of Alabama School of Medicine, 619 19th Street South, JT-920, Birmingham, AL, 35249-6810, USA
| | - Arthur M Boudreaux
- Department of Anesthesiology, University of Alabama School of Medicine, 619 19th Street South, JT-823, Birmingham, AL, 35249-6810, USA
| | - Thomas R Hunt
- Division of Orthopedics, University of Alabama School of Medicine, 1313 13th Street South, OSB Suite 201, Birmingham, AL, 35205, USA
- Department of Surgery, University of Alabama School of Medicine, 1313 13th Street South, OSB Suite 201, Birmingham, AL, 35205, USA
| | - Keith A Jones
- Department of Anesthesiology, University of Alabama School of Medicine, 619 19th Street South, JT-804, Birmingham, AL, 35249-6810, USA
| | - Jean-Francois Pittet
- Department of Anesthesiology, University of Alabama School of Medicine, 619 19th Street South, JT-926, Birmingham, AL, 35249-6810, USA
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Siegal E. A structured approach to medical comanagement of surgical patients. ITALIAN JOURNAL OF MEDICINE 2012. [DOI: 10.1016/j.itjm.2012.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Webster F, Bremner S, Jackson M, Bansal V, Sale J. The impact of a hospitalist on role boundaries in an orthopedic environment. J Multidiscip Healthc 2012; 5:249-56. [PMID: 23055744 PMCID: PMC3468163 DOI: 10.2147/jmdh.s36316] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Purpose Hospitalists specialize in the management of hospitalized patients. They work with several health care professionals to provide patient care. There has been little research examining the perceived impact of the hospitalist’s role on staff working in an orthopedic environment. This study examined the experiences of staff across several professional backgrounds in working with a hospitalist in an orthopedic environment. Participants and methods A qualitative descriptive approach was taken to investigate the experience of staff working with a hospitalist at a specialized orthopedic hospital. Purposive sampling was used to recruit interview participants including nurses, internists, pharmacists, physiotherapists, anesthetists, senior administration, and orthopedic surgeons to the point of theoretical saturation, which occurred after 12 interviews. Interviews were coded, and these codes were combined into categories and predominant themes were identified. Findings Overall, staff believed that the hospitalist role was a positive addition to the facility. The role benefitted patients and supported the clinical well-being and education of staff. Many staff felt the hospitalist had no impact on their workload, but others reported that their work had decreased or increased. Several described the potential for role overlap between the hospitalist and other physicians. Conclusion The importance of interprofessional collaboration in the implementation of the hospitalist role was a recurring theme in our analysis. This study demonstrates the importance of educating staff about the hospitalist role boundaries prior to implementing hospitalist care.
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Affiliation(s)
- Fiona Webster
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
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Chadaga SR, Maher MP, Maller N, Mancini D, Mascolo M, Sharma S, Anderson ML, Chu ES. Evolving practice of hospital medicine and its impact on hospital throughput and efficiencies. J Hosp Med 2012; 7:649-54. [PMID: 22791678 DOI: 10.1002/jhm.1951] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2011] [Revised: 05/01/2012] [Accepted: 05/06/2012] [Indexed: 11/09/2022]
Abstract
Hospitalists are uniquely positioned to implement strategies to improve patient flow and efficiency. Hospital leaders have stated they expect hospitalists to comanage surgical patients, participate in observation units, and screen medical admissions, in addition to providing inpatient care for medical patients. We review how the hospitalists' role in acute inpatient care, surgical comanagement, short stay units, chest pain units, and active bed management has improved throughput and patient flow.
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Affiliation(s)
- Smitha R Chadaga
- Division of Hospital Medicine, Department of Medicine, Denver Health Medical Center, Denver, Colorado 80204-4507, USA.
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Siegal E. Co-Management of the Surgical Patient. Perioper Med (Lond) 2012. [DOI: 10.1002/9781118375372.ch2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Abstract
BACKGROUND Hospitalist comanagement of complex surgical and medical specialty patients is increasingly common, but it is unclear how provider expectations and experiences under the collaborative practice model differ from those of traditional consultations. METHODS We analyzed survey data examining expectations and experiences on a medical hepatology comanagement service. Participating hospitalists, nonphysician providers (NPPs), hepatologists, and fellows completed a Baseline Survey that addressed preferences for decision-making under comanagement. Repeated Surveys, administered to each unique team of comanagers, addressed their experiences with decision-making on their rotations on the service between April and October 2008. RESULTS All 43 providers completed the Baseline Survey. Among these, 32 providers who rotated on the service completed 79% (177/223) of Repeated Surveys. The majority of respondents indicated understanding their role. More providers of every professional role indicated their preference for hospitalists to participate in every management decision and for hepatologists not to participate in every management decision. Most indicated that they both preferred and experienced the direction of management issues by a single physician leader. Almost all indicated at baseline that comanagement tends to improve patient care (hospitalists 94%, hepatologists 83%, NPPs 100%, fellows 100%), although fewer NPPs (40%) and fellows (50%) felt comanagement actually improved care following their rotations. CONCLUSIONS Preferences and experiences about provider roles are not uniform under comanagement, and conflicting preferences exist around decision-making processes. Providers generally agreed that comanaging hospitalists should participate broadly in management decisions.
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Affiliation(s)
- Keiki Hinami
- Division of Hospital Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
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Hinami K, Whelan CT, Konetzka RT, Edelson DP, Casalino LP, Meltzer DO. Effects of provider characteristics on care coordination under comanagement. J Hosp Med 2010; 5:508-13. [PMID: 20635410 DOI: 10.1002/jhm.797] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Care coordination is critical in settings characterized by high levels of uncertainty, time constraints, and interdependent work processes. The effects of provider characteristics on coordination in comanaged teams has never been examined. OBJECTIVE To characterize individual providers based on their contribution to team coordination. PARTICIPANTS Hospitalists, nonphysician providers, hepatologists, and fellows on a comanaged liver service of an academic hospital. DESIGN Between April 2008 and October 2008, participants were surveyed at baseline and repeatedly at the completion of physician rotations to assess their preferred and actual comanagement structures. In addition, they repeatedly rated their comanagers' contributions to overall coordination using an instrument that assessed relational coordination (RC). Providers were categorized into tertiles of RC. Their management preferences and the frequency of a "composite bad outcome" (intensive care unit [ICU] transfer or inpatient death) in each tertile were evaluated. RESULTS All (100%) Baseline Surveys and 177/224 (79%) Repeated Surveys were completed by 32 providers. RC was shown to be a stable attribute of providers and not of adverse patient outcomes. Higher coordinators were characterized by their "ownership of patients" (higher 86% vs. lowest 20%, P < 0.01). High compared to low coordinator hepatologists demonstrated leadership through a broader delegation of tasks as well as self-assignment of responsibilities. A trend toward more frequent "composite bad outcomes" was seen for low tertile physicians: hospitalists (low 8.6% vs. high 1.1%, P < 0.01), hepatologists (low 5.2% vs. high 2.0%, P = 0.22), fellows (low 5.8% vs. high 1.8%, P = 0.08). CONCLUSION Individual provider's teamwork-related disposition affects perceived coordination on comanaged team and may influence patient outcomes.
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Affiliation(s)
- Keiki Hinami
- Division of Hospital Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
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Kim CS, Lovejoy W, Paulsen M, Chang R, Flanders SA. Hospitalist time usage and cyclicality: opportunities to improve efficiency. J Hosp Med 2010; 5:329-34. [PMID: 20803670 DOI: 10.1002/jhm.613] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Academic medical centers (AMCs) have a constrained resident work force. Many AMCs have increased the use of nonresident service hospitalists to manage continued growth in clinical volume. To optimize their time in the hospital, it is important to understand hospitalists' work flow. DESIGN We performed a time-motion study of hospitalists carrying the admission pager throughout the 3 types of shifts we have at our hospital (day shift, swing shift, and night shift). SETTING Tertiary academic medical center in the Midwest. RESULTS Hospitalists spend about 15% of their time on direct patient care, and two-thirds of their time on indirect patient care. Of the indirect activities, communication and documentation dominate. Travel demands make up over 7% of a hospitalists' time. There are spikes in indirect patient care, followed closely by spikes in direct patient care, at shift changes. CONCLUSIONS At our AMC, indirect patient care activities accounted for the majority of the admitting hospitalists' time spent in the hospital, with documentation and communication dominating this time. Travel takes a significant fraction of hospitalists' time. There is also a cyclical nature to activities performed throughout the day, which can cause patient delays and impose variability on support services. There is a need for both service-specific and systemic improvements for AMCs to efficiently manage further growth in their inpatient volume.
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Affiliation(s)
- Christopher S Kim
- Division of General Internal Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan 48109-5376, USA
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Means RT, Moliterno DJ, Allison GR, Perman JA, Lofgren RP, Karpf M, Debeer FC. The evolution of a Department of Internal Medicine under an integrated clinical enterprise model: the University of Kentucky experience. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2010; 85:531-537. [PMID: 20182134 DOI: 10.1097/acm.0b013e3181ccd9ac] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
The impact on the Department of Internal Medicine of the emergence of the University of Kentucky Healthcare Enterprise as an integrated clinical model has been enormous. In fiscal year 2004, the department was financially insolvent and on the verge of implementing plans to decrease faculty from 127 to 65. Since that time, the department has changed dramatically with a corresponding improvement in its clinical, academic, and financial activity. The department has grown to 175 faculty, with a healthy financial outlook and a shared vision with the clinical enterprise. Departmental clinical growth has been accompanied by growth in extramural research funding. The clinical growth of the department, in turn, supported the growth of the integrated clinical enterprise overall.The purpose of this article is to present a case history of the impact of transition to an integrated clinical enterprise financial model on the clinical, research, and educational functions of a department of internal medicine, and the opportunities and lessons learned from this transition. The implementation of an enterprise model allowed revival and expansion of the clinical programs of the department. This expansion did not occur at the expense of the research and educational missions of the department but, rather, was associated with improved performance in these areas. The processes which were established during the conversion to the enterprise model, which involve strategic planning, monitoring of plan implementation, recalibration of objectives, financial transparency, and accountability of leadership and faculty, may better prepare the institution to face the challenges of the rapidly changing economic environment.
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Affiliation(s)
- Robert T Means
- Department of Internal Medicine, University of Kentucky College of Medicine, Lexington, Kentucky, USA.
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Feldman MD, Petersen AJ, Tice JA. "On the other hand ...": the evidence does not support the use of hand-carried ultrasound by hospitalists. J Hosp Med 2010; 5:168-71. [PMID: 20235286 DOI: 10.1002/jhm.604] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
In the right hands, ultrasound is a safe and helpful diagnostic imaging tool. However, evidence supporting the use of hand-carried ultrasound (HCU) by hospitalist physicians has not kept pace with expanding application of these devices. In spite of its strategic point-of-care benefit, use of this technology by hospitalists may not ultimately translate into improved efficiency and better clinical outcomes. Optimal levels of training in image acquisition and interpretation remain to be established. Novelty, availability, and the results of a few small studies lacking patient-centered outcomes remain insufficient grounds to justify the expanded clinical utilization of these medical imaging devices by nonspecialists.
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Affiliation(s)
- Mitchell D Feldman
- Department of Medicine, Division of General Internal Medicine, University of California, San Francisco, California 94143-0320, USA.
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Pinzur MS, Gurza E, Kristopaitis T, Monson R, Wall MJ, Porter A, Davidson-Bell V, Rapp T. Hospitalist-orthopedic co-management of high-risk patients undergoing lower extremity reconstruction surgery. Orthopedics 2009; 32:495. [PMID: 19634848 DOI: 10.3928/01477447-20090527-14] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The introduction of the hospitalist co-management model represents an opportunity to improve care by changing the system as it applies to a small group of patients. Eighty-six consecutive patients with multiple comorbidities were selectively enrolled in an academic medical center hospitalist-orthopedic surgery co-management patient care program. Patients were stratified by all patient refined diagnosis-related groups, severity of illness, and risk of mortality. Hospital length of stay, cost of care, in-hospital mortality, complications, and intensive care unit admissions were compared with a retrospectively constructed control group of 54 patients undergoing similar surgery during the period immediately preceding initiation of the program. The University Health System Consortium observed-to-expected ratio for hospital length of stay was 0.693 compared to 0.862 for the control group. The severity of illness and risk of mortality scores represented a relatively higher risk stratification in the study group. While the overall observed-to-expected cost of care remained virtually unchanged, the positive impact of the study model revealed an increased positive effect on the more severely affected severity of illness and risk of mortality patients. The results of this study suggest that a proactive, cooperative, co-management model for the perioperative management of high-risk patients undergoing complex surgery can improve the quality and efficiency metrics associated with the delivery of service to patients.
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Affiliation(s)
- Michael S Pinzur
- Department of Orthopedic Surgery, Loyola University Medical Center, 2160 S First Avenue, Maywood, IL 60153, USA
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