Impact of hospitalist comanagement on vascular surgery inpatient outcomes

Objective

In recent years, hospitalists have been increasingly involved in the medical management of hospitalized surgical patients. This trend has been impacted by the goal of offloading inpatient care from the primary care provider in addition to the presence of an increasing burden of inpatient comorbidities and broader trends in multidisciplinary team-based care of the surgical patient. Multiple studies have demonstrated the clinical benefits associated with the implementation of a hospitalist comanagement service for surgical patients, whereas others have highlighted increases in cost and strain on understaffed medical teams. We aimed to assess the impact of the implementation of a dedicated hospitalist comanagement agreement on outcomes in an academic medical center vascular surgery inpatient service.

Methods

Institutional review board approval was obtained before data collection. The inpatient database was queried for all admissions to the vascular surgery service between January 1, 2007, and December 31, 2017. Given that a hospitalist comanagement agreement was established in 2014, we collected data and compared cohorts admitted to the vascular surgery service before and after January 1, 2014. Patients admitted to the intensive care unit during their hospital stay were excluded, as the hospitalist team was not involved in intensive care unit patient care. We collected data on patient demographics, admission diagnosis, comorbid diseases, and clinical outcomes including hospital length of stay, cardiac morbidity, and mortality. Data were assessed via logistic regression models to investigate the impact on clinical outcomes after the start date of the hospitalist comanagement program.

Results

A total of 1438 patients were included in the analysis, including 866 pre- and 572 posthospitalist comanagement agreement. The mean age was 66.1 (standard deviation 14.0) years, similar in both groups. Overall, 822 (57.2%) patients were male, and 616 (42.8%) were female, similar in both groups. Overall, 67.5% were White, 25.6% Black, and 6.9% were classified as other race. The mean length of stay was 8.2 days overall and was lower in the comanagement group at 7.6 vs 8.6 days in the non-comanagement group (P = .0022). Overall 30-day mortality was 2.5%, similar in both groups (P = .36). The incidence of myocardial infarction was lower in the comanagement group at 2.6% vs 6.0% in the non-comanagement group (P = .0001). Logistic regression modeling controlling for comorbidities demonstrated a 61% odds reduction rate for cardiac events in patients who were comanaged by the hospitalist medicine team (P < .01). Linear regression modeling showed an overall reduced length of stay in the comanagement group by 1.45 days (P < .01) with benefits shown specifically for patients undergoing major amputation, thromboembolectomy, and those with infected vascular grafts (3.8, 7.4, and 8.4 fewer days, respectively).

Conclusions

The implementation of a hospitalist medicine comanagement care system for vascular surgery inpatients was associated with a decrease in cardiac events and hospital length of stay. These findings encourage future investigation into additional clinical benefits and financial implications of hospitalist comanagement in the vascular surgery inpatient population.