Comanagement on a Neurosurgery Service

Collaboration between surgeons and internists (generally hospitalists) in the form of comanagement of nonsurgical aspects of inpatient perioperative hospital care has become increasingly common, according to researchers. There have been few studies on the effect of comanagement on costs and outcomes; those that have been done have focused on patients undergoing orthopedic surgical procedures. Results have suggested a modest reduction in postsurgical complications of joint replacement surgery, but few other beneficial effects on outcomes. Researchers recently conducted a retrospective, interrupted time-series analysis of data to estimate the effect of comanagement on key outcomes for patients admitted to a neurosurgery service at a university-affiliated teaching hospital. They reported results in Archives of Internal Medicine [2010;170(22):2004-2010]. Data on length of stay, costs, inpatient mortality rate, and 30-day readmission rate between 25 months before and 18 months after July 1, 2007, the date of implementation of a hospitalist-neurosurgery comanagement service (comanagement on neurosurgery service [CNS]), were analyzed. A concurrent control group was created using data on patients ≥18 years of age admitted for major noncardiac surgery at the same facility. Prior to implementation of CNS, neurosurgical patients were cared for by surgical attending physicians, 5 residents, 3 pharmacists, and 4 to 5 nurse practitioners. Residents, pharmacists, and nurse practitioners shared responsibilities for order writing, while the cross-covering resident handled management of acute issues. Consultation with a hospitalist on general medical issues was infrequent. After implementation of CNS, a hospitalist was available daily from 7:30 AM to 7:30 PM to actively participate in management of patients on the neurosurgery service. Prespecified criteria for comanagement included a history of coronary artery disease, congestive heart failure, serious arrhythmias, chronic obstructive pulmonary disease, chronic kidney disease, ischemic stroke, diabetes mellitus requiring insulin therapy, or long-term anticoagulation therapy. Applying the inclusion criteria produced an average daily census of 13 to 16 patients, approximately one third of the total neurosurgical census. A total of 7596 patients were admitted to the neurosurgery service during the study period: 55.3% (n=4203) before implementation of CNS on July 1, 2007, and 44.7% (n=3393) after initiation of comanagement. Of the 3393 patients admitted after initiation of CNS, 29.1% (n=988) were comanaged. After adjustments for patient characteristics and background trends and accounting for clustering at the physician level, there were no significant differences in mortality rate, readmission, or length of stay after implementation of CNS compared with the period before initiation of comanagement. Analyses revealed a moderate decrease in adjusted hospital costs after implementation (adjusted cost ratio, 0.94; range, 0.88-1.00). The decrease was the equivalent of a savings of $1439 per admission. To assess patient satisfaction, 1456 patients were surveyed by telephone (801 prior to implementation of CNS and 646 after initiation of comanagement). After adjusting in multivariable models, there were no consistent improvements in patient satisfaction following implementation of CNS. Surveys were also distributed to nonnurse healthcare professionals (n=31; 18 in the before group and 13 in the after group). Survey results revealed strong support for CNS, with the strongest positive changes being associated with perception of improved attention to medical issues during hospitalization and at discharge. Nurses surveyed (31 in the before group and 34 in the after group) also had positive perceptions of the effect of CNS on patient care. The strongest positive change seen among nurses was on questions regarding handling of medical issues during hospitalization. In conclusion, the researchers summarized that implementation of CNS had little effect on patient outcomes or satisfaction, but did reduce hospital costs. They noted that “as comanagement models are adopted, more emphasis should be placed on developing systems that improve patient outcomes.”