title: Vascular surgeon-hospitalist comanagement improves in-hospital mortality at the expense of increased in-hospital cost.
abstract: OBJECTIVE
  We have shown that vascular surgeon- hospitalist co management resulted in improved in-hospital mortality rates. We now aim to assess the impact of the hospitalist co management service (HCS) on healthcare cost.
  
  
  METHODS
  A total of 1558 patients were divided into three cohorts and compared: 516 in 2012, 525 in 2013, and 517 in 2014. The HCS began in January 2013. Data were standardized for six vascular surgeons that were present 2012-2014. New attendings were excluded. Ten hospitalists participated. Case mix index (CMI), contribution margin, total hospital charges (THCs), length of stay (LOS), actual direct costs (ADCs), and actual variable indirect costs (AVICs) were compared. Analysis of variance with post-hoc tests, t-tests, and linear regressions were performed.
  
  
  RESULTS
  THC rose by a mean difference of $14,578.31 between 2012 and 2014 (P < .001) with a significant difference found between all groups during the study period (P = .0004). ADC increased more than AVIC; however, both significantly increased over time (P = .0002 and P = .014, respectively). A mean $3326.63 increase in ADC was observed from 2012 to 2014 (P < .0001). AVIC only increased by an average $392.86 during the study period (P = .01). This increased cost was observed in the context of a higher CMI and longer LOS. CMI increased from 2.25 in 2012 to 2.53 in 2014 (P = .006). LOS increased by a mean 1.02 days between 2012 and 2014 (P = .016), and significantly during the study period overall (P = .018). After adjusting for CMI, LOS increases by only 0.61 days between 2012 and 2014 (P = .07). In a final regression model, THC is independently predicted by comanagement, CMI, and LOS. After adjusting for CMI and LOS, the increase in THC because of comanagement (2012 vs 2014) accounts for only $4073.08 of the total increase (P < .001). During this time, 30-day readmission rates decreased by ∼7% (P = .005), while related 30-day readmission rates decreased by ∼2% (P = .32). Physician contribution margin remained unchanged over the 3-year period (P = .76). The most prevalent diagnosis-related group was consistent across all years. Variation in the principal diagnosis code was observed with the prevalence of circulatory disorders because of type II diabetes replacing atherosclerosis with gangrene as the most prevalent diagnosis in 2013 and 2014 compared with 2012.
  
  
  CONCLUSIONS
  In-hospital cost is significantly higher since the start of the HCS. This surge may relate to increased CMI, LOS, and improved coding. This increase in cost may be justified as we have observed sustained reduction in in-hospital mortality and slightly improved readmission rates.
authors.affiliation: Division of Vascular Surgery, Department of Surgery, 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, Icahn School of Medicine at Mount Sinai, New York, NY.
authors.forename: Melissa L
authors.initials: ML
authors.lastname: Tardiff
authors.affiliation: Division of Vascular Surgery, Department of Surgery, 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, University of Rochester Medical Center, Rochester, NY.
authors.forename: Michael
authors.initials: M
authors.lastname: Stoner
authors.affiliation: Division of Vascular Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY.
authors.forename: Chien Yi M
authors.initials: CY
authors.lastname: Png
authors.affiliation: Division of Vascular Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY.
authors.forename: David
authors.initials: D
authors.lastname: Kaplan
authors.affiliation: Division of Vascular Surgery, Department of Surgery, 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, Icahn School of Medicine at Mount Sinai, New York, NY.
authors.forename: Michael L
authors.initials: ML
authors.lastname: Marin
mesh_terms: D003299:Cooperative Behavior; D019033:Delivery of Health Care, Integrated / Q000191:economics; D003953:Diagnosis-Related Groups / Q000191:economics; D006302:Health Services Research; D017722:Hospital Charges; D017721:Hospital Costs; D017052:Hospital Mortality; D020445:Hospitalists / Q000191:economics*; D006801:Humans; D033183:Interdisciplinary Communication; D007902:Length of Stay / Q000191:economics; D016014:Linear Models; D018803:Models, Economic; D009519:New York City; D010348:Patient Care Team / Q000191:economics*; D010359:Patient Readmission / Q000191:economics; D015397:Program Evaluation; D058996:Quality Improvement / Q000191:economics; D019984:Quality Indicators, Health Care / Q000191:economics; D012189:Retrospective Studies; D012307:Risk Factors; D013038:Specialization / Q000191:economics*; D066231:Surgeons / Q000191:economics*; D013997:Time Factors; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000191:economics* / Q000401:mortality*; D000078329:Workforce