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Associations Between the Hospitalist Model of Care and Quality-of-Care-Related Outcomes in Patients Undergoing Hip Fracture Surgery
ORIGINAL ARTICLE HOSPITALIST CONSULTS FOR HIP SURGERY
Associations Between the Hospitalist Model of Care and Quality-of-Care–Related Outcomes in Patients Undergoing Hip Fracture Surgery ARCHANA ROY, MD; MICHAEL G. HECKMAN, MS; AND VIVEK ROY, MD
OBJECTIVE: To investigate the relationship between the hospitalist consultant model of care and both length of hospital stay (LOS) and hospital cost for patients undergoing hip fracture surgery. PATIENTS AND METHODS: We retrospectively studied 118 consecutive patients admitted with hip fracture (diagnosis related groups 79.35 and 81.52) between January 1, 2002, and December 31, 2002, at a community-based academic medical center. For each patient, consultations for preoperative medical evaluation and management of postoperative complications were performed by a hospitalist or a traditional medical consultant (nonhospitalist). We defined “hospitalist” as dedicated hospital-based physicians who provide their maximum professional time in inpatient health care delivery and who are completely free of outpatient responsibilities. Time to consultation (TTC), time to surgery (TTS), LOS, and total hospital costs were determined for each patient by review of the medical records and were compared between hospitalist and nonhospitalist consultants. RESULTS: Both TTC and TTS were significantly lower for hospitalist patients (P<.001 and P=.004, respectively). Although not statistically significant, cost and LOS also were lower for patients receiving hospitalist care. In the hospitalist group, median cost was an estimated $1777 less, and median LOS was 1 day less than in the nonhospitalist group. CONCLUSION: Hospitalist involvement in the medical management of patients undergoing hip fracture surgery may be associated with decreases in TTC, TTS, LOS, and total hospital cost. The results of this study have implications for consultative medical care of patients undergoing urgent surgery and their health outcomes.
Mayo Clin Proc. 2006;81(1):28-31 CI = confidence interval; LOS = length of hospital stay; PCP = primary care physician; TTC = time to consultation; TTS = time to surgery
T
he hospitalist movement represents a relatively new model of health care delivery in the United States. The field has grown rapidly in both number of hospitalists and their sphere of activity. This increase is largely fueled by published research showing improved efficiency of care and improved outcomes with hospitalists’ involvement in the care of medical patients.1-3 Hospitalists are increasingly
From the Division of Hospital Internal Medicine (A.R.), Biostatistics Unit (M.G.H.), and Division of Hematology/Oncology (V.R.), Mayo Clinic College of Medicine, Jacksonville, Fla. Individual reprints of this article are not available. Address correspondence to Archana Roy, MD, Division of Hospital Internal Medicine, Mayo Clinic College of Medicine, 4500 San Pablo Rd, Jacksonville, FL 32224 (e-mail: roy.archana @mayo.edu). © 2006 Mayo Foundation for Medical Education and Research
28
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•
participating in the medical management of surgical patients, including those undergoing emergency surgery. Traditionally, a patient’s primary care physician (PCP) or a subspecialist (eg, cardiologist or pulmonologist) provides medical consultation to surgical patients; however, a recent study showed improved outcomes with surgeon-hospitalist joint care in patients undergoing elective hip and knee arthroplasty.4 The effect of hospitalist involvement in the medical care of patients with hip fractures undergoing emergency surgery has not been studied. Hip fracture surgery is a commonly performed, highvolume surgical procedure in most hospitals. Patients with hip fracture are usually elderly and have multiple comorbid conditions, which increases surgical risk. The procedure often must be performed urgently; timely surgery has been shown to be associated with improved outcomes.5 Appropriate and timely preoperative medical evaluation of these patients and optimization of medical management before and after surgery are therefore critical for ensuring the best possible outcomes. In our institution, the hospitalist consult program was established in July 2001 to provide timely medical care for surgical patients. This study was designed to compare outcomes between the hospitalist consultant model of care and the traditional medical consultant (nonhospitalist) model for patients undergoing hip fracture surgery. Specifically, we compared the time to consultation (TTC), time to surgery (TTS), length of hospital stay (LOS), and hospital costs between hospitalists and nonhospitalists. PATIENTS AND METHODS This study was performed at a 281-bed community-based academic medical center affiliated with Mayo Clinic in Jacksonville, Fla. Community physicians and Mayo Clinic physicians admit patients to and perform surgery in this hospital. Community patients are followed up by community physicians including PCPs (internists, family physicians) or subspecialists. Independent community hospitalists also admit patients and provide medical care to surgical patients in this hospital on behalf of the patient’s PCP. Patients of Mayo Clinic are admitted to our medical or surgical services and followed up by our residents and consultants.
January 2006;81(1):28-31
•
www.mayoclinicproceedings.com
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
HOSPITALIST CONSULTS FOR HIP SURGERY
This study consisted of 118 consecutive patients admitted through the emergency department with a diagnosis of hip fracture (diagnosis related groups 79.35 and 81.52) between January 1, 2002, and December 31, 2002. Medical service was consulted for preoperative medical evaluation and postoperative management. For community patients, a PCP (internist, family physician, or subspecialist) was consulted for preoperative medical evaluation. Independent hospitalists were consulted if a patient’s PCP was not available or at the request of the patient’s PCP. Patients who had a Mayo Clinic physician as their PCP were admitted to our institutional orthopedic surgery service. A hospitalist was consulted for all Mayo Clinic patients except family medicine patients for whom a family medicine resident was consulted. Hospitalists provided consultation for all unassigned patients. This study was approved by the Mayo Foundation Institutional Review Board. DATA COLLECTION Data were collected electronically by personnel from the Office of Patient Affairs/Outcomes Management who were not aware of the aims of this study and were verified by an independent observer not included in this study. The following information was collected for each patient: age, sex, American Society of Anesthesiologists score, presence of disease (diabetes mellitus, hypertension, congestive heart failure, coronary artery disease, or chronic obstructive pulmonary disease), date of admission, date of surgery, date of discharge, date and time of preoperative medical consultation request, date and time of consultation completion, and total cost of care. From this information, TTC (the length of time from request to completion of consultation), TTS (the length of time from admission to surgery), and LOS were calculated for each patient. STATISTICAL ANALYSES Patient characteristics were summarized with the sample median and range or number and percentage of patients. The Wilcoxon rank sum test and the Fisher exact test were used to compare patient characteristics and outcomes according to model of care. Confidence intervals (95% CIs) were calculated for the median LOS, TTC, and cost. An exact binomial 95% CI was used to estimate the proportion of patients with a TTS of less than 24 hours. Statistical significance was determined at the 5% level. RESULTS Table 1 shows patient characteristics according to model of care. Although not statistically significant, hospitalist patients were slightly older than nonhospitalist patients (P=.07). Cost, TTC, TTS, and LOS are summarized in Mayo Clin Proc.
•
TABLE 1. Patient Characteristics* Patient group Characteristic Median (IQR) age (y) Women ASA score 2 3 4 Diabetes mellitus CAD CHF Hypertension COPD Renal insufficiency†
Hospitalist (n=47)
Nonhospitalist (n=71)
84 (80-88) 37 (79)
81 (77-87) 60 (85)
12 (26) 25 (53) 10 (21) 16 (34) 29 (62) 7 (15) 32 (68) 4 (9) 4 (9)
7 (10) 56 (79) 8 (11) 25 (35) 36 (51) 9 (13) 43 (61) 10 (14) 7 (10)
P value .07 .47 .59
>.99 .26 .79 .44 .41 >.99
*Values are number (percentage) of patients unless indicated otherwise. ASA = American Society of Anesthesiologists; CAD = coronary artery disease; CHF = congestive heart failure; COPD = chronic obstructive pulmonary disease; IQR = interquartile range. †Defined as creatinine value >177 µmol/L (2 mg/dL).
Table 2 according to model of care. Although not statistically significant, LOS (P=.06) and cost (P=.08) were lower for the hospitalist group than the nonhospitalist group. Median cost for hospitalist patients was $11,043 compared with $12,820 for nonhospitalist patients. Median LOS was 5 days for hospitalist patients and 6 days for other patients. Both TTS and TTC were significantly lower for patients receiving hospitalist care (P=.004 and P<.001, respectively). DISCUSSION In this retrospective study, we showed that, compared with traditional consultant involvement, hospitalist involvement in the medical management of patients undergoing hip fracture surgery may be associated with decreases in TTC, TTS, LOS, and hospital cost. Several studies investigating hospitalist and nonhospitalist models of care for general internal medicine patients show that the hospitalist model results in improved outcomes.1-3,6-10 However, studies examining the effects of TABLE 2. TTC, TTS, LOS, and Hospital Cost According to Model of Care* Patient group Variable
Hospitalist (n=47)
Nonhospitalist (n=71)
P value
TTC (h) TTS (%)† LOS (d) Cost ($)
3.0 (2.0-3.8) 32 (19-47) 5 (4-5) 11,043 (9395-13,150)
15.9 (12.0-17.5) 11 (5-21) 6 (5-6) 12,820 (12,132-14,800)
<.001 .004 .06 .08
*Values are estimated median or percentage (95% confidence interval). LOS = length of hospital stay; TTC = time to consultation; TTS = time to surgery. †Percentage of patients with a TTS <24 hours.
January 2006;81(1):28-31
•
www.mayoclinicproceedings.com
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
29
HOSPITALIST CONSULTS FOR HIP SURGERY
the hospitalist model on surgical patients are limited. A recently published study on hospitalist and surgical comanagement of patients after elective knee and hip arthroplasty showed a decrease in minor complications for hospitalist patients but did not show a decrease in LOS or cost.4 No other studies have investigated the association between model of care and quality-of-care−related outcomes in surgical patients. Several factors may be responsible for the improved outcomes observed in the hospitalist group. Timing of consultations and surgery is important in acute care. The TTC (P<.001) and TTS (P=.004) were lower in the hospitalist group, which may be due to the greater availability of hospitalists. Because hospitalists are available on-site 24 hours a day, they are able to reach patients more quickly than traditional consultants. Availability is also important for timely management of postoperative medical complications. That timely consultation and surgery should be associated with improved patient outcomes is not only intuitive but also supported by the literature.5,11-14 Although the benefits of earlier hip surgery have never been evaluated in a randomized trial, the relationship between timing of surgery and outcomes has been examined.5,11-14 A recently published study found that surgery for hip fracture within 24 hours of admission may be a desirable goal.5 In that study, surgery within 24 hours was associated with decreased pain, shorter LOS, and probably fewer major complications.5 In our study, a higher percentage of patients in the hospitalist group had surgery within 24 hours, and this group also had an LOS 1 day shorter and 14% less hospital cost than the nonhospitalist group. Studies with general internal medicine patients have shown the efficiency of hospitalists by reductions in LOS and cost.2,15-20 The study of hospitalist and surgical comanagement in elective hip and knee arthroplasty did not show significant reduction in unadjusted LOS (admission to discharge) but did show a reduction of 0.5 days in adjusted LOS (patient ready to be discharged) with hospitalist involvement.4 Further study is needed to understand the mechanism of these effects. Better performance with increased experience is the rule in medicine. The medical literature describes improved outcomes and efficiency when an intensivist participates in the treatment of critically ill patients.21-23 Similar findings have been reported for geriatricians.12,24,25 In a consult hospitalist program, hospitalists devote substantial clinical time to the management of surgical patients and thus become more experienced in the care of these patients. Expertise gained with experience by consulting hospitalists may be another reason for improved outcomes in this group. Differences in practice style between hospitalists and traditional consultants may be another reason for the differ30
Mayo Clin Proc.
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ence in outcomes. In our program, a hospitalist consultant usually makes rounds on their surgical patients twice a day and sometimes more depending on the severity of illness. Multiple rounds by hospitalists help in early recognition and treatment of complications, which can be expected to lead to less direct and indirect hospital cost. The availability of hospitalists in the evening hours to discuss management plans with patients and their family members facilitates discharge planning and may be another contributory factor for reduction in LOS with hospitalist care. Another difference in the practice styles of hospitalists and traditional consultants at our institution is that hospitalist consultants closely monitor their surgical patients postoperatively for at least 24 to 48 hours, possibly longer, depending on the patient’s comorbid conditions. Elderly patients with coronary artery disease or its risk factors are at high risk for postoperative cardiac complications, and optimization of medical management is critical for prevention of complications and for improved patient outcomes. Although efficiency-related issues have been the driving force in the growth of the hospitalist model of care, our study suggests that its potential advantages extend beyond cost containment. Timely consultation is associated with improved outcomes and reduced hospital cost. These results have important implications for organization of consultative medical services for surgical patients. Although not specifically analyzed in our study, we speculate that the benefits seen in the hospitalist group also may be associated with higher patient and staff satisfaction. We acknowledge the limitations of this study. Because of the study’s retrospective nature, our findings should be considered hypothesis generating rather than firm conclusions. Our findings may not be applicable to situations other than hip fracture surgery. More prospective research is needed to corroborate our findings in different patient groups and to formally evaluate the mechanism of the effects and cost-effectiveness of hospitalist involvement in the medical care of surgical patients. CONCLUSION We show that, in comparison to traditional consultants, hospitalists may provide consultative services more efficiently, which leads to decreased TTC, TTS, LOS, and hospital cost. These study results have implications for consultative medical care of patients undergoing urgent surgery and their health outcomes. We thank Angela Young and Sarah Bernard for their help in data collection and Marc D. Cohen, MD, for his administrative support of the study.
January 2006;81(1):28-31
•
www.mayoclinicproceedings.com
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
HOSPITALIST CONSULTS FOR HIP SURGERY
REFERENCES 1. Wachter RM, Goldman L. The emerging role of “hospitalists” in the American health care system. N Engl J Med. 1996;335:514-517. 2. Davis KM, Koch KE, Harvey JK, Wilson R, Englert J, Gerard PD. Effects of hospitalists on cost, outcomes, and patient satisfaction in a rural health system. Am J Med. 2000;108:621-626. 3. Auerbach AD, Wachter RM, Katz P, Showstack J, Baron RB, Goldman L. Implementation of a voluntary hospitalist service at a community teaching hospital: improved clinical efficiency and patient outcomes. Ann Intern Med. 2002;137:859-865. 4. Huddleston JM, Long KH, Naessens JM, et al, Hospitalist-Orthopedic Team Trial Investigators. Medical and surgical comanagement after elective hip and knee arthroplasty: a randomized, controlled trial. Ann Intern Med. 2004;141:28-38. 5. Orosz GM, Magaziner J, Hannan EL, et al. Association of timing of surgery for hip fracture and patient outcomes. JAMA. 2004;291:1738-1743. 6. Lindenauer PK, Pantilat SZ, Katz PP, Wachter RM. Hospitalists and the practice of inpatient medicine: results of a survey of the National Association of Inpatient Physicians. Ann Intern Med. 1999;130:343-349. 7. Meltzer D, Manning WG, Morrison J, et al. Effects of physician experience on costs and outcomes on an academic general medicine service: results of a trial of hospitalists. Ann Intern Med. 2002;137:866-874. 8. Palmer HC, Armistead NS, Elnicki DM, et al. The effect of a hospitalist service with nurse discharge planner on patient care in an academic teaching hospital. Am J Med. 2001;111:627-632. 9. Wachter RM, Flanders S. The hospitalist movement and the future of academic general internal medicine. J Gen Intern Med. 1998;13:783-785. 10. Wachter RM, Katz P, Showstack J, Bindman AB, Goldman L. Reorganizing an academic medical service: impact on cost, quality, patient satisfaction, and education. JAMA. 1998;279:1560-1565. 11. Hoenig H, Rubenstein LV, Sloane R, Horner R, Kahn K. What is the role of timing in the surgical and rehabilitative care of community-dwelling older persons with acute hip fracture? [published correction appears in Arch Intern Med. 1997;157:1444]. Arch Intern Med. 1997;157:513-520. 12. Zuckerman JD, Sakales SR, Fabian DR, Frankel VH. Hip fractures in geriatric patients: results of an interdisciplinary hospital care program. Clin Orthop. 1992;274:213-225.
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13. Rogers FB, Shackford SR, Keller MS. Early fixation reduces morbidity and mortality in elderly patients with hip fractures from low-impact falls. J Trauma. 1995;39:261-265. 14. Bredahl C, Nyholm B, Hindsholm KB, Mortensen JS, Olesen AS. Mortality after hip fracture: results of operation within 12 h of admission. Injury. 1992;23:83-86. 15. Hackner D, Tu G, Braunstein GD, Ault M, Weingarten S, Mohsenifar Z. The value of a hospitalist service: efficient care for the aging population? Chest. 2001;119:580-589. 16. Diamond HS, Goldberg E, Janosky JE. The effect of full-time faculty hospitalists on the efficiency of care at a community teaching hospital. Ann Intern Med. 1998;129:197-203. 17. Kaboli PJ, Barnett MJ, Rosenthal GE. Associations with reduced length of stay and costs on an academic hospitalist service. Am J Manag Care. 2004; 10:561-568. 18. Stein MD, Hanson S, Tammaro D, Hanna L, Most AS. Economic effects of community versus hospital-based faculty pneumonia care. J Gen Intern Med. 1998;13:774-777. 19. Craig DE, Hartka L, Likosky WH, Caplan WM, Litsky P, Smithey J. Implementation of a hospitalist system in a large health maintenance organization: the Kaiser Permanente experience. Ann Intern Med. 1999;130:355-359. 20. Freese RB. The Park Nicollet experience in establishing a hospitalist system. Ann Intern Med. 1999;130:350-354. 21. Manthous CA, Amoateng-Adjepong Y, Al-Kharrat T, et al. Effects of a medical intensivist on patient care in a community teaching hospital. Mayo Clin Proc. 1997;72:391-399. 22. Pollack MM, Katz RW, Ruttimann UE, Getson PR. Improving the outcome and efficiency of intensive care: the impact of an intensivist. Crit Care Med. 1988;16:11-17. 23. Young MP, Birkmeyer JD. Potential reduction in mortality rates using an intensivist model to manage intensive care units. Eff Clin Pract. 2000;3:284289. 24. Whitaker JJ, Currie CT. Non-orthopaedic problems in the elderly on an acute orthopaedic unit: the case for geriatrician input. Health Bull (Edinb). 1989;47:72-77. 25. Murphy PJ, Rai GS, Lowy M, Bielawska C. The beneficial effects of joint orthopaedic-geriatric rehabilitation. Age Ageing. 1987;16:273-278.
January 2006;81(1):28-31
•
www.mayoclinicproceedings.com
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
31
Associations Between the Hospitalist Model of Care and Quality-of-Care–Related Outcomes in Patients Undergoing Hip Fracture Surgery ARCHANA ROY, MD; MICHAEL G. HECKMAN, MS; AND VIVEK ROY, MD
OBJECTIVE: To investigate the relationship between the hospitalist consultant model of care and both length of hospital stay (LOS) and hospital cost for patients undergoing hip fracture surgery. PATIENTS AND METHODS: We retrospectively studied 118 consecutive patients admitted with hip fracture (diagnosis related groups 79.35 and 81.52) between January 1, 2002, and December 31, 2002, at a community-based academic medical center. For each patient, consultations for preoperative medical evaluation and management of postoperative complications were performed by a hospitalist or a traditional medical consultant (nonhospitalist). We defined “hospitalist” as dedicated hospital-based physicians who provide their maximum professional time in inpatient health care delivery and who are completely free of outpatient responsibilities. Time to consultation (TTC), time to surgery (TTS), LOS, and total hospital costs were determined for each patient by review of the medical records and were compared between hospitalist and nonhospitalist consultants. RESULTS: Both TTC and TTS were significantly lower for hospitalist patients (P<.001 and P=.004, respectively). Although not statistically significant, cost and LOS also were lower for patients receiving hospitalist care. In the hospitalist group, median cost was an estimated $1777 less, and median LOS was 1 day less than in the nonhospitalist group. CONCLUSION: Hospitalist involvement in the medical management of patients undergoing hip fracture surgery may be associated with decreases in TTC, TTS, LOS, and total hospital cost. The results of this study have implications for consultative medical care of patients undergoing urgent surgery and their health outcomes.
Mayo Clin Proc. 2006;81(1):28-31 CI = confidence interval; LOS = length of hospital stay; PCP = primary care physician; TTC = time to consultation; TTS = time to surgery
T
he hospitalist movement represents a relatively new model of health care delivery in the United States. The field has grown rapidly in both number of hospitalists and their sphere of activity. This increase is largely fueled by published research showing improved efficiency of care and improved outcomes with hospitalists’ involvement in the care of medical patients.1-3 Hospitalists are increasingly
From the Division of Hospital Internal Medicine (A.R.), Biostatistics Unit (M.G.H.), and Division of Hematology/Oncology (V.R.), Mayo Clinic College of Medicine, Jacksonville, Fla. Individual reprints of this article are not available. Address correspondence to Archana Roy, MD, Division of Hospital Internal Medicine, Mayo Clinic College of Medicine, 4500 San Pablo Rd, Jacksonville, FL 32224 (e-mail: roy.archana @mayo.edu). © 2006 Mayo Foundation for Medical Education and Research
28
Mayo Clin Proc.
•
participating in the medical management of surgical patients, including those undergoing emergency surgery. Traditionally, a patient’s primary care physician (PCP) or a subspecialist (eg, cardiologist or pulmonologist) provides medical consultation to surgical patients; however, a recent study showed improved outcomes with surgeon-hospitalist joint care in patients undergoing elective hip and knee arthroplasty.4 The effect of hospitalist involvement in the medical care of patients with hip fractures undergoing emergency surgery has not been studied. Hip fracture surgery is a commonly performed, highvolume surgical procedure in most hospitals. Patients with hip fracture are usually elderly and have multiple comorbid conditions, which increases surgical risk. The procedure often must be performed urgently; timely surgery has been shown to be associated with improved outcomes.5 Appropriate and timely preoperative medical evaluation of these patients and optimization of medical management before and after surgery are therefore critical for ensuring the best possible outcomes. In our institution, the hospitalist consult program was established in July 2001 to provide timely medical care for surgical patients. This study was designed to compare outcomes between the hospitalist consultant model of care and the traditional medical consultant (nonhospitalist) model for patients undergoing hip fracture surgery. Specifically, we compared the time to consultation (TTC), time to surgery (TTS), length of hospital stay (LOS), and hospital costs between hospitalists and nonhospitalists. PATIENTS AND METHODS This study was performed at a 281-bed community-based academic medical center affiliated with Mayo Clinic in Jacksonville, Fla. Community physicians and Mayo Clinic physicians admit patients to and perform surgery in this hospital. Community patients are followed up by community physicians including PCPs (internists, family physicians) or subspecialists. Independent community hospitalists also admit patients and provide medical care to surgical patients in this hospital on behalf of the patient’s PCP. Patients of Mayo Clinic are admitted to our medical or surgical services and followed up by our residents and consultants.
January 2006;81(1):28-31
•
www.mayoclinicproceedings.com
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
HOSPITALIST CONSULTS FOR HIP SURGERY
This study consisted of 118 consecutive patients admitted through the emergency department with a diagnosis of hip fracture (diagnosis related groups 79.35 and 81.52) between January 1, 2002, and December 31, 2002. Medical service was consulted for preoperative medical evaluation and postoperative management. For community patients, a PCP (internist, family physician, or subspecialist) was consulted for preoperative medical evaluation. Independent hospitalists were consulted if a patient’s PCP was not available or at the request of the patient’s PCP. Patients who had a Mayo Clinic physician as their PCP were admitted to our institutional orthopedic surgery service. A hospitalist was consulted for all Mayo Clinic patients except family medicine patients for whom a family medicine resident was consulted. Hospitalists provided consultation for all unassigned patients. This study was approved by the Mayo Foundation Institutional Review Board. DATA COLLECTION Data were collected electronically by personnel from the Office of Patient Affairs/Outcomes Management who were not aware of the aims of this study and were verified by an independent observer not included in this study. The following information was collected for each patient: age, sex, American Society of Anesthesiologists score, presence of disease (diabetes mellitus, hypertension, congestive heart failure, coronary artery disease, or chronic obstructive pulmonary disease), date of admission, date of surgery, date of discharge, date and time of preoperative medical consultation request, date and time of consultation completion, and total cost of care. From this information, TTC (the length of time from request to completion of consultation), TTS (the length of time from admission to surgery), and LOS were calculated for each patient. STATISTICAL ANALYSES Patient characteristics were summarized with the sample median and range or number and percentage of patients. The Wilcoxon rank sum test and the Fisher exact test were used to compare patient characteristics and outcomes according to model of care. Confidence intervals (95% CIs) were calculated for the median LOS, TTC, and cost. An exact binomial 95% CI was used to estimate the proportion of patients with a TTS of less than 24 hours. Statistical significance was determined at the 5% level. RESULTS Table 1 shows patient characteristics according to model of care. Although not statistically significant, hospitalist patients were slightly older than nonhospitalist patients (P=.07). Cost, TTC, TTS, and LOS are summarized in Mayo Clin Proc.
•
TABLE 1. Patient Characteristics* Patient group Characteristic Median (IQR) age (y) Women ASA score 2 3 4 Diabetes mellitus CAD CHF Hypertension COPD Renal insufficiency†
Hospitalist (n=47)
Nonhospitalist (n=71)
84 (80-88) 37 (79)
81 (77-87) 60 (85)
12 (26) 25 (53) 10 (21) 16 (34) 29 (62) 7 (15) 32 (68) 4 (9) 4 (9)
7 (10) 56 (79) 8 (11) 25 (35) 36 (51) 9 (13) 43 (61) 10 (14) 7 (10)
P value .07 .47 .59
>.99 .26 .79 .44 .41 >.99
*Values are number (percentage) of patients unless indicated otherwise. ASA = American Society of Anesthesiologists; CAD = coronary artery disease; CHF = congestive heart failure; COPD = chronic obstructive pulmonary disease; IQR = interquartile range. †Defined as creatinine value >177 µmol/L (2 mg/dL).
Table 2 according to model of care. Although not statistically significant, LOS (P=.06) and cost (P=.08) were lower for the hospitalist group than the nonhospitalist group. Median cost for hospitalist patients was $11,043 compared with $12,820 for nonhospitalist patients. Median LOS was 5 days for hospitalist patients and 6 days for other patients. Both TTS and TTC were significantly lower for patients receiving hospitalist care (P=.004 and P<.001, respectively). DISCUSSION In this retrospective study, we showed that, compared with traditional consultant involvement, hospitalist involvement in the medical management of patients undergoing hip fracture surgery may be associated with decreases in TTC, TTS, LOS, and hospital cost. Several studies investigating hospitalist and nonhospitalist models of care for general internal medicine patients show that the hospitalist model results in improved outcomes.1-3,6-10 However, studies examining the effects of TABLE 2. TTC, TTS, LOS, and Hospital Cost According to Model of Care* Patient group Variable
Hospitalist (n=47)
Nonhospitalist (n=71)
P value
TTC (h) TTS (%)† LOS (d) Cost ($)
3.0 (2.0-3.8) 32 (19-47) 5 (4-5) 11,043 (9395-13,150)
15.9 (12.0-17.5) 11 (5-21) 6 (5-6) 12,820 (12,132-14,800)
<.001 .004 .06 .08
*Values are estimated median or percentage (95% confidence interval). LOS = length of hospital stay; TTC = time to consultation; TTS = time to surgery. †Percentage of patients with a TTS <24 hours.
January 2006;81(1):28-31
•
www.mayoclinicproceedings.com
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
29
HOSPITALIST CONSULTS FOR HIP SURGERY
the hospitalist model on surgical patients are limited. A recently published study on hospitalist and surgical comanagement of patients after elective knee and hip arthroplasty showed a decrease in minor complications for hospitalist patients but did not show a decrease in LOS or cost.4 No other studies have investigated the association between model of care and quality-of-care−related outcomes in surgical patients. Several factors may be responsible for the improved outcomes observed in the hospitalist group. Timing of consultations and surgery is important in acute care. The TTC (P<.001) and TTS (P=.004) were lower in the hospitalist group, which may be due to the greater availability of hospitalists. Because hospitalists are available on-site 24 hours a day, they are able to reach patients more quickly than traditional consultants. Availability is also important for timely management of postoperative medical complications. That timely consultation and surgery should be associated with improved patient outcomes is not only intuitive but also supported by the literature.5,11-14 Although the benefits of earlier hip surgery have never been evaluated in a randomized trial, the relationship between timing of surgery and outcomes has been examined.5,11-14 A recently published study found that surgery for hip fracture within 24 hours of admission may be a desirable goal.5 In that study, surgery within 24 hours was associated with decreased pain, shorter LOS, and probably fewer major complications.5 In our study, a higher percentage of patients in the hospitalist group had surgery within 24 hours, and this group also had an LOS 1 day shorter and 14% less hospital cost than the nonhospitalist group. Studies with general internal medicine patients have shown the efficiency of hospitalists by reductions in LOS and cost.2,15-20 The study of hospitalist and surgical comanagement in elective hip and knee arthroplasty did not show significant reduction in unadjusted LOS (admission to discharge) but did show a reduction of 0.5 days in adjusted LOS (patient ready to be discharged) with hospitalist involvement.4 Further study is needed to understand the mechanism of these effects. Better performance with increased experience is the rule in medicine. The medical literature describes improved outcomes and efficiency when an intensivist participates in the treatment of critically ill patients.21-23 Similar findings have been reported for geriatricians.12,24,25 In a consult hospitalist program, hospitalists devote substantial clinical time to the management of surgical patients and thus become more experienced in the care of these patients. Expertise gained with experience by consulting hospitalists may be another reason for improved outcomes in this group. Differences in practice style between hospitalists and traditional consultants may be another reason for the differ30
Mayo Clin Proc.
•
ence in outcomes. In our program, a hospitalist consultant usually makes rounds on their surgical patients twice a day and sometimes more depending on the severity of illness. Multiple rounds by hospitalists help in early recognition and treatment of complications, which can be expected to lead to less direct and indirect hospital cost. The availability of hospitalists in the evening hours to discuss management plans with patients and their family members facilitates discharge planning and may be another contributory factor for reduction in LOS with hospitalist care. Another difference in the practice styles of hospitalists and traditional consultants at our institution is that hospitalist consultants closely monitor their surgical patients postoperatively for at least 24 to 48 hours, possibly longer, depending on the patient’s comorbid conditions. Elderly patients with coronary artery disease or its risk factors are at high risk for postoperative cardiac complications, and optimization of medical management is critical for prevention of complications and for improved patient outcomes. Although efficiency-related issues have been the driving force in the growth of the hospitalist model of care, our study suggests that its potential advantages extend beyond cost containment. Timely consultation is associated with improved outcomes and reduced hospital cost. These results have important implications for organization of consultative medical services for surgical patients. Although not specifically analyzed in our study, we speculate that the benefits seen in the hospitalist group also may be associated with higher patient and staff satisfaction. We acknowledge the limitations of this study. Because of the study’s retrospective nature, our findings should be considered hypothesis generating rather than firm conclusions. Our findings may not be applicable to situations other than hip fracture surgery. More prospective research is needed to corroborate our findings in different patient groups and to formally evaluate the mechanism of the effects and cost-effectiveness of hospitalist involvement in the medical care of surgical patients. CONCLUSION We show that, in comparison to traditional consultants, hospitalists may provide consultative services more efficiently, which leads to decreased TTC, TTS, LOS, and hospital cost. These study results have implications for consultative medical care of patients undergoing urgent surgery and their health outcomes. We thank Angela Young and Sarah Bernard for their help in data collection and Marc D. Cohen, MD, for his administrative support of the study.
January 2006;81(1):28-31
•
www.mayoclinicproceedings.com
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
HOSPITALIST CONSULTS FOR HIP SURGERY
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