title: The effect of a hospitalist comanagement service on vascular surgery inpatients.
abstract: OBJECTIVE
  Vascular surgery patients have increased medical comorbidities that amplify the complexity of their care. We assessed the effect of a hospitalist comanagement service on inpatient vascular surgery outcomes.
  
  
  METHODS
  We divided 1059 patients into two cohorts for comparison: 515 between January 2012 and December 2012, before the implementation of a hospitalist comanagement service, and 544 between January 2013 and October 2013, after the initiation of a hospitalist comanagement service. Nine vascular surgeons and 10 hospitalists participated in the hospitalist comanagement service. End points measured were in-hospital mortality, length of stay (LOS), 30-day readmission rates, visual analog scale pain scores (0-10), inpatient adult safety assessments using the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators, and resident perceptions assessed by survey.
  
  
  RESULTS
  The in-hospital mortality rate decreased from 1.75% to 0.37% after the implementation of the hospitalist comanagement service (P = .016), with a decrease in the observed-to-expected ratio from 0.89 to 0.22. The risk-adjusted in-hospital mortality decreased from 1.56% to 0.0008% (P = .003). Mean LOS was lower in the base period, at 5.1 days vs 5.5 days (P < .001), with an observed-to-expected ratio of 0.83 and 0.78, respectively. The risk-adjusted LOS increased from 4.2 days to 4.3 days (P < .001). The overall 30-day readmission rate was unchanged, at 23.1% compared with 22.8% (P = .6). The related 30-day readmission rate was also similar, at 11.5% compared with 11.4% (P = .5). Patients reporting no pain during hospitalization increased from 72.8% before the hospitalist comanagement service to 77.8% after (P = .04). Reports of moderate pain decreased from 14% to 9.6% (P = .016). Mild and severe pain scores were similar between the two groups. Adult safety measured by AHRQ demonstrated a decrease from three to zero patients in the number of deaths among surgical patients with treatable complications (P = .04). Most house staff reported that the comanagement program had a positive effect on patient care and education.
  
  
  CONCLUSIONS
  The hospitalist comanagement service has resulted in a significant decrease in in-hospital mortality rates, patient safety, as measured by AHRQ, and improved pain scores. Resident surveys demonstrated perceived improvement in patient care and education. Continued observation will be necessary to assess the long-term effect of the hospitalist comanagement service on quality metrics.
authors.affiliation: Division of Vascular Surgery, Department of Surgery, The Icahn School of Medicine at Mount Sinai, New York, NY. Electronic address: rami.tadros@mountsinai.org.
authors.forename: Rami O
authors.initials: RO
authors.lastname: Tadros
authors.affiliation: Division of Vascular Surgery, Department of Surgery, The Icahn School of Medicine at Mount Sinai, New York, NY.
authors.forename: Peter L
authors.initials: PL
authors.lastname: Faries
authors.affiliation: Division of Vascular Surgery, Department of Surgery, The Icahn School of Medicine at Mount Sinai, New York, NY.
authors.forename: Rajesh
authors.initials: R
authors.lastname: Malik
authors.affiliation: Division of Vascular Surgery, Department of Surgery, The Icahn School of Medicine at Mount Sinai, New York, NY.
authors.forename: Ageliki G
authors.initials: AG
authors.lastname: Vouyouka
authors.affiliation: Division of Vascular Surgery, Department of Surgery, The Icahn School of Medicine at Mount Sinai, New York, NY.
authors.forename: Windsor
authors.initials: W
authors.lastname: Ting
authors.affiliation: Division of Hospitalist Medicine, Department of Medicine, The Icahn School of Medicine at Mount Sinai, New York, NY.
authors.forename: Andrew
authors.initials: A
authors.lastname: Dunn
authors.affiliation: Division of Vascular Surgery, Department of Surgery, The Icahn School of Medicine at Mount Sinai, New York, NY.
authors.forename: Michael L
authors.initials: ML
authors.lastname: Marin
authors.affiliation: Division of Hospitalist Medicine, Department of Medicine, The Icahn School of Medicine at Mount Sinai, New York, NY.
authors.forename: Alan
authors.initials: A
authors.lastname: Briones
mesh_terms: D001291:Attitude of Health Personnel; D015897:Comorbidity; D019033:Delivery of Health Care, Integrated / Q000592:standards; D007722:Health Knowledge, Attitudes, Practice; D017052:Hospital Mortality; D020445:Hospitalists / Q000523:psychology / Q000592:standards; D006801:Humans; D007297:Inpatients; D007902:Length of Stay; D009519:New York City; D010147:Pain Measurement; D010149:Postoperative Pain / Q000175:diagnosis / Q000209:etiology; D010348:Patient Care Team / Q000592:standards; D010359:Patient Readmission; D061214:Patient Safety; D015397:Program Evaluation; D019984:Quality Indicators, Health Care; D012189:Retrospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D011795:Surveys and Questionnaires; D013997:Time Factors; D016896:Treatment Outcome; D014652:Vascular Diseases / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000401:mortality / Q000592:standards