Hospitalist-vascular surgery comanagement: effects on complications and mortality

Abstract

Objectives: 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.

Keywords: Comanagement; hospitalist; patient safety; quality improvement; vascular surgery.