Hospitalist-vascular surgery comanagement: effects on complications and mortality.
OBJECTIVE
Hospitalized vascular surgery patients have multiple severe comorbidities, poor functional status, and high perioperative cardiac risk. Thus they may be ideal patients for a collaborative care model. However, there is little evidence for a comanagement model on clinical outcomes.


METHODS
The two-year pre-post study consisted of a comanagement model where a hospitalist actively participated in the medical care of American Society of Anesthesiologist Physical Status Classification scale 3 or 4 vascular surgery patients. Outcomes were in-hospital mortality, length of stay, 30-day readmission rate, pain scores, and patient safety metrics.


RESULTS
With comanagement, patient complications decreased from 3.5 to 2.2 events per 1000 patients. (p = 0.045). Mortality decreased from 2.01% to 1.00% (p = 0.049), corresponding to a decrease in the risk-adjusted observed to expected mortality rate ratio from 1.22 to 0.53 (p = 0.01). Patient reported pain scores improved; more patients in the comanagement cohort expressed no pain (72% vs 82.8%; p = 0.01) and there were reductions in reports of mild and moderate pain. There was no significant difference in the risk-adjusted length of stay (observed to expected ratio 0.83 to 0.88 for the pre-intervention and comanagement groups, respectively, p = 0.48). The 30-day readmission rate was unchanged (21.9 vs 20.6% p = 0.44). Patients in the intervention period were more clinically complex, as evidenced by the greater case mix index (2.21 vs 2.44).


CONCLUSIONS
After two years of implementation, our comanagement service reduced complications, mortality, and pain scores among high-risk vascular surgery patients.
a Division of Hospital Medicine , The Mount Sinai Hospital , New York , NY , USA.
Colin T
CT
Iberti
a Division of Hospital Medicine , The Mount Sinai Hospital , New York , NY , USA.|b Division of Hospital Medicine , University of Miami Health System , FL , USA.
Alan
A
Briones
a Division of Hospital Medicine , The Mount Sinai Hospital , New York , NY , USA.
Erin
E
Gabriel
a Division of Hospital Medicine , The Mount Sinai Hospital , New York , NY , USA.
Andrew S
AS
Dunn
D000368:Aged; D003299:Cooperative Behavior; D005260:Female; D006746:Hospital Bed Capacity, 500 and over; D017052:Hospital Mortality; D020445:Hospitalists / Q000458:organization & administration* / Q000706:statistics & numerical data*; D006801:Humans; D019458:Insurance Coverage; D007348:Insurance, Health; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D059408:Pain Management / Q000706:statistics & numerical data; D010346:Patient Care Management / Q000458:organization & administration; D010348:Patient Care Team / Q000458:organization & administration; D010359:Patient Readmission / Q000706:statistics & numerical data; D061214:Patient Safety; D011183:Postoperative Complications / Q000517:prevention & control*; D012189:Retrospective Studies; D016019:Survival Analysis; D062606:Tertiary Care Centers; D014656:Vascular Surgical Procedures / Q000009:adverse effects* / Q000401:mortality
Comanagement; hospitalist; patient safety; quality improvement; vascular surgery