Background: Based on the 2016 State of Hospital Medicine Report, 87% of hospital medicine groups provide surgical comanagement services. Despite its popularity, when studied, the benefits are inconsistent. The vast majority of comanagement research evaluates the process of initiating a program, but there is little to no research on the outcomes of discontinuing a service. We evaluated the effect on administrative metrics (Length of stay, 30-day readmission) and clinical utilization (Echocardiogram testing) upon discontinuing a comanagement service.
Methods: We examined all discharges from the vascular surgery service at an urban academic medical center during a year of active comanagement vs. a post-discontinuation year (PDY). During comanagement, the hospitalists were responsible for all aspects of medical care including preoperative orders and assessments. After the comanagement service was discontinued, a medical consultation service was available. The main outcomes measured were length of stay (LOS), 30-day readmission rates and echocardiogram (echo) utilization. For each discharge, demographic and diagnosis data were extracted from our clinical information system. Discharges during the two time periods were compared with respect to LOS, 30-day readmission rate and echo utilization using chi-squared and Wilcoxon rank-sum tests as appropriate. All outcomes were assessed in an unadjusted and adjusted analysis using linear and regression models.
Results: The study included 636 patients in the active comanagement period and 663 patients in the post discontinuation year (PDY). The PDY was associated with a 0.88 day increase in LOS (8.49 vs. 7.61, p=0.06), which remained after adjusting for age, gender, race/ethnicity and DRG-weight (0.81 day increase, p=0.048). The PDY was associated with a non-significant decrease in 30-day readmission rate (19.5% vs. 23.4%, OR = 0.79, p=0.08), which remained in the adjusted analysis. The PDY was associated with a significant increase in echo utilization (36.4% vs. 28.8%, OR 1.41, p = 0.004), which remained in the adjusted analysis.
Conclusions: The discontinuation of a comanagement program was associated with an increase in LOS and echo utilization and a non-significant decrease in 30-day readmissions. Given the pervasiveness of comanagement as a model of care, administrators should be aware of the potential consequences of discontinuing a service given its potential effect on utilization.