Comanagement of hospitalized surgical patients by medicine physicians in the United States

Abstract

Background: Comanagement of surgical patients by medicine physicians (generalist physicians or internal medicine subspecialists) has been shown to improve efficiency and to reduce adverse outcomes. We examined the extent to which comanagement is used during hospitalizations for common surgical procedures in the United States.

Methods: We conducted a retrospective cohort study of Medicare fee-for-service beneficiaries hospitalized for 1 of 15 inpatient surgical procedures from 1996 to 2006 (n = 694 806). We also calculated the proportion of Medicare beneficiaries comanaged by medicine physicians (generalist physicians or internal medicine subspecialists) during hospitalization. Comanagement was defined by relevant physicians (generalist or internal medicine subspecialist) submitting a claim for evaluation and management services on 70% or more of the days that the patients were hospitalized.

Results: Between 1996 and 2006, 35.2% of patients hospitalized for a common surgical procedure were comanaged by a medicine physician: 23.7% by a generalist physician and 14% by an internal medicine subspecialist (2.5% were comanaged by both). The percentage of patients experiencing comanagement was relatively unchanged from 1996 to 2000 and then increased sharply. The increase was entirely attributable to a surge in comanagement by generalist physicians. In a multivariable multilevel analysis, comanagement by generalist physicians increased 11.4% per year from 2001 to 2006. Patients with advanced age, with more comorbidities, or receiving care in nonteaching, midsize (200-499 beds), or for-profit hospitals were more likely to receive comanagement. All of the growth in comanagement was attributed to increased comanagement by hospitalist physicians.

Conclusions: Medical comanagement of Medicare beneficiaries hospitalized for a surgical procedure is increasing because of the increasing role of hospitalists. To meet this growing need for comanagement, training in internal medicine should include medical management of surgical patients.

Figure 1. Trends in comanagement^a of patients hospitalized for a surgical procedure between 1996 and 2006 by a generalist physician^b, internal medicine sub-specialist^c or any medicine physician^d

^aA patient is defined as “having comanagement” if any medicine physician submitted evaluation and management (E&M) claims for at least 70% of the days during the patients hospital stay for a surgical procedure. ^bAny medicine physician: either a generalist physician or an internal medicine subspecialist ^cGeneralist physician includes: internal medicine physician, geriatrician, family practitioner or a general practitioner ^dInternal medicine subspecialist includes: pulmonary, cardiology, gastroenterology, endocrinology, rheumatology, nephrology, infectious disease and hematology/oncology. For all point estimates the 95% confidence interval are less than 0.5% and are not shown.

Figure 2. Trends in medical comanagement by type of surgery for patients hospitalized for a surgical procedure between 1996 and 2006

General surgery includes cholecystectomy (DRG 493, 195, 196, 197, 198) and resection for colorectal cancer (DRG 148, 149), Vascular surgery includes abdominal aortic aneurysm repair (DRG 110), lower extremity revascularization (DRG 553, 554, 478) and major leg amputation (DRG 113, 213, 285) Cardiothoracic surgery includes coronary artery bypass grafting (DRG 105, 547, 548, 549, 550), aortic/mitral valve replacement (DRG 104, 105) and lung resection for cancer (DRG 75) Urology includes radical prostatectomy (DRG 334), transurethral resection of the prostrate for BPH (476, 306) and radical nephrectomy for renal cancer (DRG 303) Orthopedic surgery includes back surgery (DRG 496, 497, 498, 499), knee replacement (DRG 544), hip replacement (DRG 544) and repair for hip fracture (DRG 210, 211, 544)