Background: Surgical co-management is a care model in which Hospitalists assist in the management of patients who are admitted for surgical indications. The surgical co-management model has been shown in some previous studies to improve patient care and outcomes. At our institution, formal co-management agreements have been devised to set clear teamwork expectations and focus Hospital Medicine resources on the highest risk patients. In this study, we sought to examine the care of Vascular Surgery patients before and after a co-management agreement was implemented, and to compare relevant clinical outcomes between the two time periods.
Methods: We performed a retrospective cohort study of all patients admitted to the Vascular Surgery service during a 36-month period, including 18 months before and after the formal Hospital Medicine co-management agreement was put in place. Baseline patient demographics were collected, along with the presence of common chronic diseases. Hospital outcomes were analyzed including hospital length of stay, discharge disposition, 30-day readmission, and frequency of subspecialty consultation. Clinical outcomes were also assessed, including glycemic control during hospitalization, frequency of acute kidney injury (AKI), and mortality. All Vascular Surgery patients admitted during the study period were included, regardless of Hospitalist involvement.
Results: In total, 516 patients were included, 212 prior to the co-management agreement intervention and 304 post-intervention. Hospital Medicine was involved in the care of 8% of Vascular Surgery service patients in the pre-intervention period compared to 22% following implementation of the co-management agreement. Pre-intervention and post-intervention patients were similar with regard to demographics and the presence of chronic medical comorbidities. Patients admitted after the co-management agreement had a similar hospital length of stay but were more likely to be discharged home rather than to a nursing facility (80.2% vs 68.2%, p=0.001) and were less likely to be readmitted within 30 days (14.5% vs 26.9%, p< 0.001). During their hospitalizations, post-intervention patients did not experience improved glycemic control or a reduction AKI incidence but did have a lower risk of mortality (1.7% vs 5.8%, p=0.013). Patients who were cared for by a Hospitalist during both periods were more likely to have diabetes (51.0% vs 29.0%, p< 0.001) and were more likely to have an AKI during their hospitalization (46.9% vs 20.9%, p< 0.001) compared to patients who were not cared for by a Hospitalist.
Conclusions: Following the implementation of a formal Vascular Surgery and Hospital Medicine co-management agreement, we observed similar length of stay but lower mortality, increased discharge home, and decreased 30-day readmission. Our findings suggest that a modest increase in Hospital Medicine involvement in the care of patients with high comorbidity and acuity of illness may lead to improvement in meaningful outcomes for hospitalized Vascular Surgery patients. Future study is needed to determine what specific factors may be driving the observed differences in outcomes, as well as how to identify the patients that may benefit most from Hospitalist consultation.